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["Form CMS-339, EXHIBIT 2A"]
[]
["LISTING OF MEDICARE BAD DEBTS"]
[]
[]
["PROVIDER NAME:                            ",null,null,null,null,null,"CCN:             ",null,null,"FYE:",null,null,"PREPARED BY:\n"]
[]
["BAD DEBTS FOR (Check Applicable BOX):                 INPATIENT                     OUTPATIENT          ",null,null,null,null,null,null,null,null,null,null,null,"DATE PREPARED:\n\n"]
[]
["CLAIM TYPE (Check Applicable BOX):           NON-DUALLY ELIGIBLE             DUALLY ELIGIBLE/CROSSOVER",null,null,null,null,null,null,null,null,null,null,null,"LISTING OF MEDICARE BAD DEBTS (CONTIUNED)"]
[]
["MEDICARE BENEFICARY DATA",null,null,null,null,null,"MEDICAID\nNUMBER","DEEMED\nINDIGENT (Y/N)","\nREMITTANCE ADVICE DATES",null,"SECONDARY\nPAYER\nREMITANCE\nADVICE\nRECEIVED\nDATE","BENEFICIARY\nRESPONSIBILE\nAMOUNT","DATE FIRST\nBILL SENT\nTO BENEFICIARY","A/R\nWRITE-OFF\nDATE","COLLECTION\nAGENCY\nINFORMATION",null,"COLLECTIONS\nEFFECTIVE\nCEASED\nDATE","MEDICARE\nWRITE-OFF\nDATE","RECOVERIES ONLY",null,"MEDICARE\nDEDUCTIBLE AND\nCOINSURANCE\nAMOUNTS*",null,"CURRENT YEAR\nPAYMENTS\nRECEIVED",null,"ALLOWABLE BAD DEBTS","COMMENTS"]
["BENEFICIARY NAME",null,"MBI OR\nHICN","PATIENT\nACCOUNT\nNUMBER","DATES OF SERVICE"]
["LAST ","FIRST",null,null,"FROM ","TO",null,null,"MEDICARE","MEDICAID",null,null,null,null,"SENT\n(Y/N)","RETURN\nDATE",null,null,"AMOUNT\nRECEIVED","\n MCR FYE\nDATE","DEDUCTIBLE","COINSURANCE","AMOUNT","SOURCE"]
["Col. 1","Col. 2","Col. 3","Col. 4","Col. 5","Col. 6","Col. 7","Col. 8","Col. 9","Col. 10","Col. 11","Col. 12","Col. 13","Col. 14","Col. 15a","Col. 15","Col. 16","Col. 17","Col. 18","Col. 19","Col. 20","Col. 21","Col. 22","Col. 23","Col. 24","Col. 25"]
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["TOTALS",null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(L16:L47)","v":0},null,null,null,null,null,null,{"$f":"SUM(S16:S47)","v":0},null,{"$f":"SUM(U16:U47)","v":0},{"$f":"SUM(V16:V47)","v":0},{"$f":"SUM(W16:W47)","v":0},null,{"$f":"SUM(Y16:Y47)","v":0}]
[]
[]
["* Report deductible and coinsurance amounts only when the provider billed the patient with the expectation of payment.  See column 8 instructions for possible exception."]
[]
["** Effective for Cost Reporting Periods starting on/after 10/1/2020."]