Thursday, June 25, 2015

How to Complete CMS-838 Credit Balance Reports

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)

Medicare Credit Balance Report – Provider Instructions


The Paperwork Burden Reduction Act of 1995 was enacted to inform you about why the Government collects information and how it uses the information. In accordance with sections 1815(a) and 1833(e) of the Social Security Act (the Act), the Secretary is authorized to request information from participating providers that is necessary to properly administer the Medicare program. In addition, section 1866(a)(1)(C) of the Act requires participating providers to furnish information about payments made to them, and to refund any monies incorrectly paid. In accordance with these provisions, all providers participating in the Medicare program are to complete a Medicare Credit Balance Report (CMS-838) to help ensure that monies owed to Medicare are repaid in a timely manner.

The CMS-838 is specifically used to monitor identification and recovery of “credit balances” owed to Medicare. A credit balance is an improper or excess payment made to a provider as the result of patient billing or claims processing errors. Examples of Medicare credit balances include instances where a provider is:

• Paid twice for the same service either by Medicare or by Medicare and another insurer;
• Paid for services planned but not performed or for non-covered services;
• Overpaid because of errors made in calculating beneficiary deductible and/or coinsurance amounts; or
• A hospital that bills and is paid for outpatient services included in a beneficiary’s inpatient claim. Credit balances would not include proper payments made by Medicare in excess of a provider’s charges such as DRG payments made to hospitals under the Medicare prospective payment system.

For purposes of completing the CMS-838, a Medicare credit balance is an amount determined to be refundable to Medicare. Generally, when a provider receives an improper or excess payment for a claim, it is reflected in their accounting records (patient accounts receivable) as a “credit.” However, Medicare credit balances include monies due the program regardless of its classification in a provider’s accounting records.

For example, if a  provider maintains credit balance accounts for a stipulated period; e.g., 90 days, and then transfers the accounts or writes them off to a holding account, this does not relieve the provider of its liability to the program. In these instances, the provider must identify and repay all monies due the Medicare program. Only Medicare credit balances are reported on the CMS-838.

To help determine whether a refund is due to Medicare, another insurer, the patient, or beneficiary, refer to the sections of the manual [each provider manual will have the appropriate cite for that manual] that pertain to eligibility and Medicare Secondary Payer (MSP) admissions procedures.

Submitting the CMS-838

Submit a completed CMS-838 to your fiscal intermediary (FI) within 30 days after the close of each calendar quarter. Include in the report all Medicare credit balances shown in your accounting records (including transfer, holding or other general accounts used to accumulate credit balance funds) as of the last day of the reporting quarter.

Report all Medicare credit balances shown in your records regardless of when they occurred. You are responsible for reporting and repaying all improper or excess payments you have received from the time you began participating in the Medicare program. Once you identify and report a credit balance on the CMS-838 report, do not report the same credit balance on subsequent CMS-838 reports.

Completing the CMS-838

The CMS-838 consists of a certification page and a detail page. An officer (the Chief Financial Officer or Chief Executive Officer) or the Administrator of your facility must sign and date the certification page. Even if no Medicare credit balances are shown in your records for the reporting quarter, you must still have the form signed and submitted to your FI in attestation of this fact. Only a signed certification page needs to be submitted if your facility has no Medicare credit balances as of the last day of the reporting quarter. An electronic file (or hard copy) of the certification page is available from your FI.

The detail page requires specific information on each credit balance on a claim-by-claim basis. This page provides space to address 17 claims, but you may add additional lines or reproduce the form as many times as necessary to accommodate all of the credit balances that you have reported. An electronic file (or hard copy) of the detail page is available from your FI.

You may submit the detail page(s) on a diskette furnished by your contractor or by a secure electronic transmission as long as the transmission method and format are acceptable to your FI. Segregate Part A credit balances from Part B credit balances by reporting them on separate detail pages.

NOTE: Part B pertains only to services you provide which are billed to your FI. It does not pertain to physician and supplier services billed to carriers.

Begin completing the CMS-838 by providing the information required in the heading area of the detail page(s) as follows:

• The full name of the facility;

• The facility’s provider number. If there are multiple provider numbers for dedicated units within the facility (e.g., psychiatric, physical medicine and rehabilitation), complete a separate Medicare Credit Balance Report for each provider number;

• The month, day and year of the reporting quarter; e.g., 12/31/02;

• An “A” if the report page(s) reflects Medicare Part A credit balances, or a “B” if it reflects Part B credit balances;

• The number of the current detail page and the total number of pages forwarded, excluding the certification page (e.g., Page 1 of 3); and

• The name and telephone number of the individual who may be contacted regarding any questions that may arise with respect to the credit balance data. Complete the data fields for each Medicare credit balance by providing the following information (when a credit balance is the result of a duplicate Medicare primary payment, report the data pertaining to the most recently paid claim):

Column 10 - The amount of the Medicare credit balance identified in column 9 being repaid with the submission of the report. (As discussed below, repay Medicare credit balances at the time you submit the CMS-838 to your FI.)

Tips on Completing a Credit Balance Report (Form CMS-838)

A Medicare credit balance is an amount determined to be refundable to the Medicare program for an improper or excess payment made to the provider because of patient billing or claims processing errors. Each provider must submit a quarterly Credit Balance Report (Form CMS-838). CGS often receives credit balance reports with missing or invalid information. Please review the following tips for completing the Credit Balance Report. In addition, for complete instructions refer to Forms/ downloads/CMS838.pdf on the Centers for Medicare & Medicaid Services (CMS) website. Information is also available in the Medicare Financial Management Manual (CMS Pub. 100-06) Chapter 12 at: http://www.cms. gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/fin106c12.pdf

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