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Jurisdiction 11 Part A
Medicare Credit Balance Report Certification Page Helpful Hints

All sections of the Medicare Credit Balance Report Certification page should be completed in their entirety.

  1. Provider Name
  2. Provider Number (only one provider per page)
  3. Quarter Ending

Check the Appropriate Box Indicating Status of the Credit Balance Report

  • There are either no credit balances to report this quarter or you have attached a credit balance report
  • Only an officer or the administrator should sign the certification page
  • Include the title of the signer
  • Indicate date for which this is completed

Due dates (30 days after quarter end)

 Quarter Quarter End Credit Balance Due
1st  March 31 On or Before April 30
2nd  June 30 On or Before July 30
3rd September 30 On or Before October 30
4th December 31  On or Before January 30

Please do not attempt to recreate your own version of this form or copy onto your letterhead paper. Make copies on plain paper and send the original document on or before the due dates. This is the required format by CMS; therefore, any changes made to this form will be unacceptable.

Mail your completed credit balance reports to one of the following addresses:

J11 North Carolina Part A

Regular and Certified Mail Overnight Courier  FacsimileTelephone Number
Palmetto GBA
Attn: Credit Balance Reporting
P.O. Box 100278
Columbia, SC 29202-3278 
Palmetto GBA
Credit Balance Reporting
2300 Springdale Drive
Building One
Camden, SC 29020 
MCBR Receipts
Attn: Credit Balance Reporting
(803) 419-3277 
(803) 763-6418

J11 South Carolina Part A/J11 HHH

Regular and Certified Mail Overnight Courier  Facsimile Telephone Number
Palmetto GBA
Attn: Credit Balance Reporting
P.O. Box 100277
Columbia, SC 29202-3277
Palmetto GBA
Credit Balance Reporting
2300 Springdale Drive
Building One
Camden, SC 29020
MCBR Receipts
Attn: Credit Balance Reporting
(803) 419-3277 
(803) 763-6418


J11 Virginia and West Virginia Part A

Regular and Certified Mail Overnight Courier  Facsimile

 Telephone Number

Palmetto GBA
Attn: Credit Balance Reporting
P.O. Box 100109
Columbia, SC 29202-3109
Palmetto GBA
Credit Balance Reporting
2300 Springdale Drive
Building One
Camden, SC 29020 
MCBR Receipts
Attn: Credit Balance Reporting
(803) 419-3277 
(803) 763-6418

Please print a copy of the Medicare Credit Balance Report Certification Page to complete it. To access this document, go to www.PalmettoGBA.com/j11a/forms.

If you have questions regarding this form, please call (803) 763-6418.


 

last updated on 10/22/2013
ver 1.0.43