DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MONTHLY INTERMEDIARY REPORT ON
MEDICARE SECONDARY PAYER SAVINGS
INTERMEDIARY NAME
NUMBER
STATE
REPORTING PERIOD (MO. & YR.)
WORKER’S COMP
TOTAL
WORKING AGED
ESRD
AUTO/NFLT
DISABLED
LIABILITY
BLACK LUNG & VA
(i)
(iii)
(iv)
(v)
(vi)
(vii)
(ii)
Unpaid
(Cost Avoided)
MSP Claims
1. Number
2. Dollar Value
Full Recoveries
3. Number
4. Dollar Value
Partial Recoveries
5. Number
6. Dollar Value
Special Projects
7. Number
8. Dollar Value
Totals
9. Number
(Lines 1+3+5+7)
10. Dollar Value
(Lines 2+4+6+8)
REMARKS
SIGNATURE
TITLE
DATE
Form CMS-1563 (11-97)