As your Medicare Administrative Contractor, Novitas Solutions, Inc. is responsible to ensure compliance with the Credit Balance reporting process. The information provided below offers a brief explanation of how the CMS-838 Credit Balance Reports should appear before mailing or faxing to Medicare.
The CMS-838 Credit Balance Report
The CMS-838 Credit Balance Report is comprised of the Certification Page and the Detail Page which is completed when there are credit balances to report. The Certification Page is required with every submission; no matter which of the following blocks are checked on the Certification Page:
Qualify as a Low Utilization Provider
The Credit Balance Report Detail Page is attached
There are no Medicare credit balances to report for this quarter (No Detail Page(s) attached).
Any Credit Balance 838-Certifications that are not accurate and complete will be deemed invalid. Effective for the 03/31/15 reporting quarter, the immediate return of invalid or incomplete CMS-838 Certification Pages will result for the following reasons. Please note that invalid Certification Pages will invalidate your entire submission:
The incorrect version of the CMS-838 Certification Page/Detail Page is received. Please use the correct version of the CMS-838 Credit Balance Report. You can type directly into this version which is strongly encouraged to ensure your report is legible. Once completed in full, the report should be printed for signatures.
Proper 6-digit Provider Transaction Access Number (PTAN) is missing, invalid, or a National Provider Identifier (NPI) is listed. The name of the facility should be indicated.
Multiple PTANS are present. Only one PTAN per Certification Page is acceptable
Incomplete or inaccurate Quarter Ending date. Quarters should be reported as 03/31/XX, 06/30/XX, 09/30/XX or 12/31/XX. Four digit years will also be acceptable.
Signature and date of Administrator is missing
Correct “Check One” block is blank or does not match the contents.
*Although Novitas will not return as invalid reports missing the Contact Person/Phone number, completing this section is necessary if contact to the provider with regard to the report is necessary.
When returning an invalid or incomplete report for the reasons listed above, you will receive a cover sheet detailing the reason for return. Your report should be corrected and mailed or faxed within the acceptable timeframe in order to avoid receiving a Delinquency Warning Letter or having 100% of your Medicare Payments withheld.
Please note that CMS-838 Detail pages are not necessary when there are no Medicare Credit Balances to report for the quarter (the third check block on the 838-Certification page). In addition, documents such as vendor reports verifying no credits, shared system reports, or other validation documents are not necessary when there are no Medicare credit balances to report.
When Medicare Credit Balances Are Identified
When reporting Medicare Credit Balances, a complete CMS-838 Detail Page is required with the submission. Although an 838-Certification Page may pass the initial validation process, the 838-Detail Page may contain inaccurate or incomplete information when reporting Medicare credit balances. Currently, telephone contact results when CMS-838 Detail Pages are incomplete or inaccurate and reports are not accepted as valid until what is requested is corrected and received timely. However, effective for the 06/30/15 reporting quarter, incomplete and/or inaccurate CMS-838 Detail Pages will be immediately returned.
Accurate and complete CMS 838-Detail Pages should include the following:
Column 1- Last name and first name of beneficiary
Column 2- Health Insurance Claim Number (HICN) of beneficiary
Column 3- Internal Control Number (ICN): Please note that this is not always the ICN of the original claim. This should be the ICN of the claim identifying the overpayment.
Column 4- Type of Bill (TOB): This is a required field and is 3-digits
Column 5- Admission Date: From date or start date service began
Column 6- Discharge Date: Through date or date service ended
Column 7- Paid Date: Date claim paid
Column 8- Cost Report: “O” is entered for a cost report period is open or “C” if closed
Column 9- Amount of Medicare Credit Balance: Total Credit Balance owed to Medicare. This is not the billed amount.
Column 10- Amount Credit Balance Repaid: This is the amount repaid with the submission of this report
Column 11- Method of Payment: The choices are “C” when remitting a check to repay the amount owed to Medicare (the check and UB04s must accompany the report), “X” when an adjustment has already been submitted through the shared system, or “A” when Novitas is expected to adjust the claim (UB04 is required)
Column 12- Amount of Medicare Credit Balance Outstanding: Column 10 minus Column 9)
Column 13- Reason for Medicare Credit Balance: The choices are “1” when a Duplicate is identified, “2” when MSP is identified, and “3” for Other.
Column 14- Value Code is required when reporting “2-MSP” in Column 13. Acceptable Value Codes are: 12-Working Aged, 13-End Stage Renal Disease (ESRD), 14-Auto/No Fault, 15-Worker’s Compensation, 16-Other Government Program, 41-Black Lung, 42-Department of Veterans Affairs (VA), 43-Disability, 44-Conditional Payment, and 47-Liability
Column 15- Name and complete billing address and is required when reporting “2-MSP” in Column 13. This column is also used to explain “3-Other” being reported in Column 13.
The following is an example of an acceptable CMS-838 Detail Page when “Duplicate” is the Reason for Medicare Credit Balance (Block 13)
The following is an example of an acceptable CMS-838 Detail Page when “MSP” is the Reason for Medicare Credit Balance (Block 13)
The following is an example of an acceptable CMS-838 Detail Page when “Other” is the Reason for Medicare Credit Balance (Block 13)