How to Complete & File CMS-838 Medicare Credit Balance Reports: A Detailed Guide

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How to Complete & File CMS-838 Medicare Credit Balance Reports: A Detailed Guide

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This detailed guide provides comprehensive instructions on how to effectively complete and submit your quarterly Medicare credit balance report form, the CMS-838, ensuring compliance with current **credit balance reporting requirements**.

Table of Contents

As your Medicare Administrative Contractor (MAC), your MAC is responsible for ensuring compliance with the Medicare credit balance report process. The information provided below offers a detailed explanation of how the CMS-838 form and its accompanying documentation should appear before submission to Medicare.

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, regardless of 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).

Understanding and Completing the CMS-838 Certification Page

Any CMS-838 Certifications that are not accurate and complete will be deemed invalid. Based on current official CMS guidelines, invalid or incomplete CMS-838 Certification Pages will be immediately returned for the following reasons. Please note that an invalid Certification Page will invalidate your entire submission:

Reasons for Invalid CMS-838 Certification Pages

  • Incorrect Version of the CMS-838: Submitting an outdated or incorrect version of the CMS-838 Certification Page/Detail Page. Always use the current version of the CMS-838 Credit Balance Report, available on the official CMS website. Typing directly into the electronic version is strongly encouraged to ensure legibility. Once completed, the report should be printed for signatures.
  • Missing or Invalid Provider Identifier: Proper 6-digit Provider Transaction Access Number (PTAN) is missing, invalid, or a National Provider Identifier (NPI) is incorrectly listed. The name of the facility should also be clearly indicated.
  • Multiple PTANs: Multiple PTANs are present on a single Certification Page. Only one PTAN per Certification Page is acceptable.
  • Incomplete or Inaccurate Quarter Ending Date: Quarters should be reported as MM/DD/YY, such as 03/31/XX, 06/30/XX, 09/30/XX, or 12/31/XX. Four-digit years (e.g., 20XX) are also acceptable.
  • Missing Administrator Signature and Date: The signature and date of the Administrator or authorized officer are required.
  • Incorrect “Check One” Block: The correct “Check One” block is blank or does not match the contents of the submission.
  • Missing Contact Information (Advisory): While current guidelines state that reports missing the Contact Person/Phone number may not be returned as invalid, completing this section is highly necessary to facilitate communication with the provider regarding the report.

When an invalid or incomplete report is returned 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 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 (as indicated by the third check block on the 838-Certification page). Furthermore, documents such as vendor reports verifying no credits, shared system reports, or other validation documents are not required when no Medicare credit balances are reported.

When Medicare Credit Balances Are Identified: Completing the Detail Page

When reporting Medicare credit balance report data, a complete CMS-838 Detail Page is required with the submission. Even if an 838-Certification Page passes the initial validation process, the 838-Detail Page may contain inaccurate or incomplete information. Current CMS guidelines emphasize accurate and complete submissions. Incomplete and/or inaccurate CMS-838 Detail Pages will be immediately returned, requiring timely correction and resubmission.

Detailed Guide to Completing the CMS-838 Detail Page Columns

Accurate and complete CMS 838-Detail Pages should include the following information for each credit balance:

  • Column 1: Last name and first name of beneficiary.
  • Column 2: Medicare Beneficiary Identifier (MBI) of the beneficiary. (Note: Health Insurance Claim Numbers (HICNs) are generally no longer accepted; MBIs are now mandatory.)
  • Column 3: Internal Control Number (ICN). This should be the ICN of the claim identifying the overpayment, not necessarily the original claim’s ICN.
  • Column 4: Type of Bill (TOB). This is a required 3-digit field.
  • Column 5: Admission Date. The ‘From’ date or start date service began.
  • Column 6: Discharge Date. The ‘Through’ date or date service ended.
  • Column 7: Paid Date. The date the claim was paid.
  • Column 8: Cost Report. Enter “O” if a cost report period is open or “C” if closed.
  • Column 9: Amount of Medicare Credit Balance. The 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. Choices are:
    • “C” when remitting a check to repay the amount owed to Medicare (the check and relevant documentation, such as **UB-04 billing details**, must accompany the report).
    • “X” when an adjustment has already been submitted through the shared system.
    • “A” when your MAC is expected to adjust the claim (relevant documentation, such as **UB-04 claim information**, is required).
  • Column 12: Amount of Medicare Credit Balance Outstanding. Calculate as Column 9 minus Column 10.
  • Column 13: Reason for Medicare Credit Balance. Choices are: “1” when a Duplicate is identified, “2” when **Medicare Secondary Payer (MSP) rules** are identified, and “3” for Other.
  • Column 14: Value Code. Required when reporting “2-MSP” in Column 13. Acceptable Value Codes include: 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. Required when reporting “2-MSP” in Column 13. This column is also used to explain “3-Other” being reported in Column 13.

Common Reasons for Medicare Credit Balances (Column 13)

To provide more practical assistance for providers reporting reason “3-Other” in Column 13, here are some common scenarios:

  • Incorrect Beneficiary Information: An error in patient identification led to an overpayment.
  • Third-Party Payment: Payment was received from another insurer or responsible party after Medicare had already paid, and the claim was not initially identified as MSP.
  • Coding Errors: Incorrect coding (e.g., upcoding) resulted in a higher reimbursement than the service was entitled to.
  • Services Not Medically Necessary: Services initially paid by Medicare were later determined not to be medically necessary.
  • Billing Duplicate Services: Unintentional billing of the same service multiple times.

Below are examples illustrating acceptable CMS-838 Detail Pages for different credit balance reasons. Please note, for a live environment, high-resolution, annotated screenshots of the current Form CMS-838 Detail Page would be embedded here to clearly highlight the columns and specific fields discussed.

  • Example: Acceptable CMS-838 Detail Page when “Duplicate” is the Reason for Medicare Credit Balance (Block 13). (Screenshot placeholder)
  • Example: Acceptable CMS-838 Detail Page when “MSP” is the Reason for Medicare Credit Balance (Block 13). (Screenshot placeholder)
  • Example: Acceptable CMS-838 Detail Page when “Other” is the Reason for Medicare Credit Balance (Block 13). (Screenshot placeholder)

Medicare Credit Balance Report – Provider Instructions

General

The Paperwork 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.

General Information on CMS-838 and Credit Balances

The CMS-838 is specifically used to monitor the 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 Form

Submit a completed CMS-838 to your fiscal intermediary (FI) or Medicare Administrative Contractor (MAC) 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.

Detailed Instructions for 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/MAC 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/MAC or the CMS Forms website.

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/MAC.

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/MAC. 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/MAC. 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/XX;
  • 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 detailed information as described in the “Detailed Guide to Completing the CMS-838 Detail Page Columns” section above. (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 above, repay Medicare credit balances at the time you submit the CMS-838 to your FI/MAC.)

Resources and Further Information

A Medicare credit balance report 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 (CMS-838 submission). Always consult your specific Medicare Administrative Contractor (MAC) for local guidelines, resources, and **compliance guidelines**. You can locate your MAC using the official CMS MAC Locator Tool.

For complete instructions and the latest guidance, refer to the current Form CMS-838 instructions on the Centers for Medicare & Medicaid Services (CMS) website. Critical information is also available in the Medicare Financial Management Manual (CMS Pub. 100-06) Chapter 12.


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