Contractor Name: ______Administrative Budget And Cost Report NOBA Certification
Address: ______Medicare Contractor Accept Date: ______
City and State: ______Notification of Budget Approval Ein: ______
Contractor No: _____ Funding FY: ____ Reporting FY: ____ Supplement No: __
**********************************************************************************************************************
Program Management Activity Summary By Function
Code Description Prod Hours Total Cost Workload
------
10000 Continuing Resolution Funds ______
10001 Continuing Resolution ______
11000 Bills/Claims Payment ______
11002 Common Working File Host ______
11003 Upin Registry Host ______
11004 CWF Acceptance Testing ______
11005 CWF Corrections Project ______
11011 HIGLAS CPG ______
11012 HIGLAS Transition ______
11022 VA Claims - Trailblazers ______
11041 Claims Reprocessed Fee Sch ______
11044 Beta Testing ______
11122 Contractor Testing Require ______
11201 Perform EDI Oversight ______
11202 Manage Paper Bills/Claims ______
11203 Manage EDI Bills/Claims ______
11204 Bills/Claims Determination ______
11205 Run Systems ______
11206 Manage Inform Sys Security ______
11207 Manage Trade Partner Agree ______
11208 Conduct Quality Assurance ______
11209 Manage Outgoing Mail ______
11210 Reopen Bills/Claims ______
11211 NonMSP Carrier Debt Collect ______
12000 Appeals/Reviews ______
12016 ALJ Database Project ______
12090 Quality Improve/Data Analys ______
12110 Part A Reconsiderations ______
12113 Part A Incomplete Recons ______
12120 Pt A ALJ Hearing Requests ______
12141 Part B Telephone Reviews ______
12142 Part B Written Reviews ______
12143 Pt B Incomplete Review Req ______
12150 Pt B Hearing Officer Hear ______
12160 Pt B ALJ Hearing Requests ______
12901 PM Cert Support ______
13000 Inquiries ______
13002 Written Inquiries ______
13004 Customer Service Plan ______
13005 Bene Telephone Inquiries ______
Contractor Name: ______Administrative Budget And Cost Report NOBA Certification
Address: ______Medicare Contractor Accept Date: ______
City and State: ______Notification of Budget Approval Ein: ______
Contractor No: _____ Funding FY: ____ Reporting FY: ____ Supplement No: __
**********************************************************************************************************************
Program Management Activity Summary By Function
13025 NGD Bene. CSR-Adminastar ______
13201 Complaint Screening ______
14000 PM Provider Communications ______
14020 Medicare Reports ______
14101 Prov/Supplier Information ______
14102 Electronic Mailing Lists ______
15000 Participating Physician ______
15001 Part Physician ______
16000 Reimbursement ______
16002 Non-MSP Debt Collection/Ref ______
16003 Interim Payment Control ______
16004 Reimbursement Report & File ______
16005 Provider Based Regulations ______
17000 Productivity Investment ______
17004 HIPAA EDI Transactions ______
17029 NDC to HCPCS Crosswalk ______
17099 Misc PIs ______
17408 Pharmaceutical Litigation ______
17844 Beta Testing for MMA ______
18000 PM Special Projects ______
18010 Storage Warehouse ______
19000 Medicare Program Adm ______
19051 BCBSA Plan Support ______
31000 Provider Enrollment ______
31001 Provider Enrollment Ongoing ______
33000 Prov Telephone Inquiries ______
33001 Prov Telephone Inquiries ______
33002 Written Prov Inquiries ______
33003 Walk In Prov Inquiries ______
33010 IVR Pilot ______
33014 Prov Quality Call Montoring ______
33020 Staff Development & Trainng ______
33025 NGD Prov. CSR-Adminastar ______
Total Credits ______
Complimentary Credit ______
Medicaid ______
Medigap ______
TOTAL ______
**********************************************************************************************************************
Contractor Name: ______Administrative Budget And Cost Report NOBA Certification
Address: ______Medicare Contractor Accept Date: ______
City and State: ______Notification of Budget Approval Ein: ______
Contractor No: _____ Funding FY: ____ Reporting FY: ____ Supplement No: __
**********************************************************************************************************************
Program Management Cumulative Quarterly Distribution
Fy First Qtr Second Qtr Third Qtr Fourth Qtr
------
______
______
______
**********************************************************************************************************************
I Certify to the Best of My Belief or Knowledge That This Data Is Accurate, Complete,
and Current as of the Execution of This Certificate
Certifying Official:______
Title:______
**********************************************************************************************************************
Program Management Accounting Information
Can: ______Object Class:____
Appropriation: ______EIN:______
**********************************************************************************************************************
Program Management Non-Cumulative Quarterly Distribution
Fy First Qtr Second Qtr Third Qtr Fourth Qtr
------
______
______
______
Program Management Distribution Change
Fy First Qtr Second Qtr Third Qtr Fourth Qtr
------
______
______
______
**********************************************************************************************************************
Remarks : ______
______
Contractor Name: ______Administrative Budget And Cost Report NOBA Certification
Address: ______Medicare Contractor Accept Date: ______
City and State: ______Notification of Budget Approval Ein: ______
Contractor No: _____ Funding FY: ____ Reporting FY: ____ Supplement No: __
**********************************************************************************************************************
Medicare Integrity Program Activity Summary By Function
Code Description Prod Hours Total Cost Workload
------
21000 Medical Review ______
21001 Prepay Automated ______
21002 Prepay Routine Manual ______
21007 Data Analysis ______
21010 TPL or Demand Bills ______
21015 LOLA ______
21100 PSC Support Services ______
21206 Policy Reconsideration ______
21207 MR Program Management ______
21208 New Policy Development ______
21210 MR Reopenings ______
21220 Complex Manual Probe Sample ______
21221 Prepay Complex Manual Rev ______
21222 Postpay Complex Manual Rev ______
21901 MIP Cert Support ______
22000 MSP Prepayment ______
22001 MSP Prepayment Claims ______
22005 Hospital Audits ______
22020 MSP Pay Module ______
23000 Benefits Integrity ______
23001 MFIS ______
23004 Outreach and Training ______
23005 Fraud Case Development ______
23006 Law Enforcement Support ______
23007 MR Support of BI Activities ______
23014 Fraud Investigation Databse ______
23015 Referrals to Law Enforcemnt ______
23100 Work Assignment 2001-8 ______
23200 PSC Support- Networking ______
23201 PSC Support-Fraud Complaint ______
24000 Local Prov Educ and Train ______
24116 One-on-One Provider Educ ______
24117 Educ Delivered to Group ______
24118 Educ Delivered Electronic ______
25000 Provider Communications ______
25103 Create/Prod/Maint Educ ______
25105 Partner W/ External Entity ______
25201 Adm & Manage of PCOM Progrm ______
25202 Develop Prov Educ Materials ______
25203 Disseminate Provider Info ______
Contractor Name: ______Administrative Budget And Cost Report NOBA Certification
Address: ______Medicare Contractor Accept Date: ______
City and State: ______Notification of Budget Approval Ein: ______
Contractor No: _____ Funding FY: ____ Reporting FY: ____ Supplement No: __
**********************************************************************************************************************
Medicare Integrity Program Activity Summary By Function
25204 Manage Operation Of PCOM ______
26000 Audit ______
26001 Provider Desk Reviews ______
26002 Provider Field Audit ______
26003 Provider Settlements ______
26004 Cost Report Reopenings ______
26005 Wage Index Review ______
26010 STAR ______
26011 PRRB & Intermed Hearings ______
26051 BCBSA PRRB/Intermediary ______
26052 BCBSA Other Audit Support ______
27000 MIP Prod Investment ______
27099 Misc PIs ______
27101 PSC Transition ______
27302 Prov Enroll Site Visits ______
27310 SADMERC - SC - General ______
27311 NSC - SC - General ______
27420 Chisholm Sulzer Project ______
28000 MIP Special Projects ______
29000 MIP Medicare Program ______
42000 MSP Postpayment ______
42002 Liability/No-Fault/Worker's ______
42003 Group Health Plan ______
42004 MSP General Inquiries ______
42021 Debt Collection/Referral ______
TOTAL ______
**********************************************************************************************************************
Remarks : ______
______
______
______
______
______
______
Contractor Name: ______Administrative Budget And Cost Report NOBA Certification
Address: ______Medicare Contractor Accept Date: ______
City and State: ______Notification of Budget Approval Ein: ______
Contractor No: _____ Funding FY: ____ Reporting FY: ____ Supplement No: __
**********************************************************************************************************************
Medicare Integrity Program Cumulative Quarterly Distribution
Fy First Qtr Second Qtr Third Qtr Fourth Qtr
------
______
______
______
**********************************************************************************************************************
I Certify to the Best of My Belief or Knowledge That This Data Is Accurate, Complete,
and Current as of the Execution of This Certificate
Certifying Official:______
Title:______
**********************************************************************************************************************
Medicare Integrity Program Accounting Information
Can: ______Object Class:____
Appropriation: ______EIN:______
**********************************************************************************************************************
Medicare Integrity Program Non-Cumulative Quarterly Distribution
Fy First Qtr Second Qtr Third Qtr Fourth Qtr
------
______
______
______
Medicare Integrity Program Distribution Change
Fy First Qtr Second Qtr Third Qtr Fourth Qtr
------
______
______
______
**********************************************************************************************************************
Remarks : ______
______