Form Cms-838 - Medicare Credit Balance Reporting Requirements Page 4

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
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
1 - The last name and first initial of the Medicare Beneficiary, (e.g., Doe, J.).
Column
2 - The Medicare Health Insurance Claim Number (HICN) of the Medicare Beneficiary.
Column
3 - The multiple-digit Internal Control Number (ICN) assigned by Medicare when the claim
is processed.
Form CMS-838 (10/03)
Page 2

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