+-----------------------------------+-----------------------------------+
| **PROGRAM MEMORANDUM**\           | **Department of Health\           |
| **INTERMEDIARIES/CARRIERS**       | and Human Services**              |
|                                   |                                   |
|                                   | **Health Care Financing\          |
|                                   | Administration**                  |
+-----------------------------------+-----------------------------------+

**Transmittal No. AB-99- 7 Date FEBRUARY 1999**

**CHANGE REQUEST 795**

SUBJECT:    Notification to Medicare Providers and Suppliers of
Beneficiary Right to an Itemized Statement

Section 4311 of the Balanced Budget Act of 1997 gives beneficiaries the
right to submit a written request for an itemized statement from their
provider or supplier for any Medicare item or service. The law also
requires providers or suppliers to furnish the itemized statement within
30 days of the request or they can be subject to a civil monetary
penalty of up to \$100 for each failure.

Program Memorandum AB-99-3 dated January 1999, ended the suppression of
the Explanation of Medicare Benefits (EOMBs) and Medicare Summary
Notices (MSNs) except for the following claim types: Laboratory,
Demonstrations, Exact Duplicates, and Statistical Adjustments. This
instruction is effective April 1, 1999, for all Carriers and
Intermediaries on the Fiscal Intermediary Standard System, and July 1,
1999, for all Intermediaries on the Arkansas Part A Standard System.

AB-99-3 further states that the following statement be included on the
EOMBs and MSNs: "You have the right to request an itemized statement
which details each Medicare item or service which you have received from
your physician, hospital, or any other health supplier or health
professional. Please contact them directly if you would like an itemized
statement."

You must prepare and disseminate provider education materials to inform
all providers and suppliers of this new requirement. The attached Notice
explains the requirements of the law relating to beneficiaries\' rights
to an itemized statement, and provides guidance on the format and
content of an itemized statement. The contents of this attachment should
be included in your next regularly scheduled bulletin. If you have an
electronic web site or bulletin board where providers or suppliers may
acquire information, post the contents of this Notice for providers or
suppliers as soon as possible.

Carrier and Intermediary Medical Directors, as well as Provider
Education staff, should share information about the itemized statement
requirements as part of their liaison and ongoing educational activities
with State and local provider organizations.

Attachment

**These instructions are to be implemented within your current operating
budget.**

**Questions regarding these instructions should be directed to
Jacqueline Proctor, (410) 786- 9019, or Harvey Tzuker, (410) 786-3670.**

**This Program Memorandum may be discarded February 1, 2000.**

**HCFA - Pub. 60 AB**

                                                                    Attachment

         NOTICE TO ALL MEDICARE PROVIDERS/SUPPLIERS

     **[Beneficiary Right to Itemized Statement for Medicare Items and
Services]{.underline}**

**A. Requirements of the Law**

Effective January 1, 1999, section 4311(b) of the Balanced Budget Act of
1997 gives beneficiaries the right to submit a written request for an
itemized statement from their provider/supplier for any Medicare item or
service. The law requires that providers/suppliers furnish the itemized
statement within 30 days of the request, or they may be subject to a
civil monetary penalty of \$100 for each unfulfilled request. If an
itemized statement is received, the beneficiary may request the Medicare
contractor to review specific issues (i.e., services not provided,
billing irregularities, and appropriate measures to recover any amount
inappropriately paid).

Medicare contractors currently issue beneficiaries an Explanation of
Medicare Benefits (EOMB) or a Medicare Summary (MSN). Information that
may be listed include the following: date(s) of services, a description
of services provided, number of services provided, benefit days used,
noncovered charges, deductible and coinsurance, beneficiary liability,
amount charged, claim number, name of provider/supplier submitting the
claim, claim total paid by Medicare and referring physician (if
applicable). Other information that may be included are deductibles,
appeal rights or notices, and explanatory notes and general information
regarding the specific claim. On April 1, 1999, at most Medicare
contractors, these notices will begin to include the following
statement: "You have a right to request an itemized statement which
details each Medicare item or service which you have received from your
physician, hospital or any other health supplier or health professional.
Please contact them directly if you would like an itemized statement."
The remaining Medicare contractors will print this message beginning
July 1, 1999.

**B. Guidance Concerning the Format and Substance of the Itemized
Statement\
**\
Included below are suggestions regarding the types of information that
might be helpful for the beneficiary to receive on an itemized
statement. We hope this information will enable the beneficiary to
reconcile the itemized statement with the Medicare notice. These are
recommendations only. Since most providers/suppliers have established an
itemized billing system for internal accounting procedures and billing
of other payers, the furnishing of an itemized statement should not pose
a significant additional burden. However, some providers/suppliers may
not regularly create or furnish hardcopy itemized statements and may
wish to reexamine their internal billing and tracking process to ensure
that it has the capability to comply with this new requirement.
Providers/suppliers should not charge beneficiaries for the itemized
statement.

[Itemized Statement Recommendations]{.underline}:

     .     Name of beneficiary,\
     .     Date(s) of services,\
     .     Description of item or service furnished,\
     .     Number of services furnished,\
     .     Provider/supplier charges,\
     .     An internal reference or tracking number\
\
If the claim has been adjudicated by Medicare, additional information
that can be included on the itemized statement are:

     .     Amounts paid by Medicare,\
     .     Beneficiary responsibility for co-insurance,\
     .     Medicare claim number

The statement should also include a name and a telephone number for the
beneficiary to call if there are further questions.

**C. Reconciliation of the Itemized Statement with the MSN/EOMB**

After receiving an itemized statement, beneficiaries may attempt to
reconcile it with the MSN or EOMB. In situations where there are
questions, especially involving some services and payment methods,
providers/suppliers are requested to assist beneficiaries in
understanding any differences between the two documents.

In addition, although Medicare contractor customer service
representatives may not have a copy of the itemized statement, they will
also answer any beneficiary inquiries regarding the EOMB/MSN and attempt
to reconcile it with the itemized statement. Where appropriate, customer
service representatives will attempt to resolve any questions by
generally explaining applicable Medicare reimbursement rules,
(prospective payment systems, revenue codes, bundling, interim rates,
HCPC/CPT codes, etc.).

**D. Beneficiary Right to Request Review of the Itemized Statement\
**\
Beneficiaries may submit a written request to their Medicare contractor
for a review of a claim based on information they provide from their
itemized statement. The request should identify the specific items or
services that the beneficiary believes were not provided as claimed, or
any other billing irregularity (including duplicate billing). A review
will be conducted into the matter by the Medicare contractor and
providers/suppliers may be requested to assist in the review of the
itemized statement/Medicare claim. Contractors will review and take
appropriate actions to resolve the complaint.

\"Return To Program Memos

\"Return to Program Manuals

Last Updated March 03, 1999

\"

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