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How to fill out the 4930 (Rev online
This guide provides comprehensive instructions for completing the 4930 (Rev), the quarterly worksheet for health insurance claims assessment. It is designed to assist users in filling out the form accurately and efficiently, ensuring compliance with the necessary requirements.
Follow the steps to successfully complete the 4930 (Rev online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Record your name, account number (FEIN, ME, or TR number), assessment/file period, and return year at the top of the form.
- Check the box indicating your organization type under Line 1. If applicable, select either the third party administrator or carrier box.
- Enter the gross paid claims during the current assessment period for dates of service on or after January 1, 2012, in Line 2.
- For Lines 3 through 13, provide amounts for each allowable exclusion only to the extent those amounts are included in Line 2.
- Calculate the net health insurance claims paid subject to assessment by subtracting the total allowable exclusions (Line 14) from the gross paid claims (Line 2) in Line 15.
- Calculate the total assessment for the file period by multiplying the amount on Line 15 by 1% (0.01) in Line 16. If you checked the box for Line 1c, use 0.1% (0.001) instead.
- If there are adjustments from previous assessment periods, enter any underpayment in Line 17 or overpayment in Line 18.
- If the assessment is paid late, complete Lines 20 and 21 by entering any penalties and calculating the total amount due, including any applicable penalty amounts.
- Finally, save your changes, and choose to download, print, or share the completed form as necessary.
Complete your 4930 (Rev online today for accurate health insurance claims assessment.
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