Medicare Program Integrity Manual 
Exhibits 
 
Table of Contents  
(Rev. 11218, Issued: 01-27-22) 
 
 
Transmittals for Exhibits 
 
1 - Definitions 
2  Allowed Services for Prior Determinations 
4 - Reliable Information 
5 - Background Information for Contractor Staff When IRP is Questioned 
5.1 - Reward Eligibility Notification Letter 
5.2 - Reward Claim Form 
5.3 - How to Use the IRP Tracking System 
5.4 - Section I:  Pending Case List Screen 
5.5 - Section II:  Pending Case List by Contractor Screen 
5.6 - Section III: New Case 
5.7 - Section IV: Closed Case List 
5.8 - Section V: Closed Case List by Contractor 
5.9 - Section VI: Report Menu 
7 - Sample Letter for On-Site Reviews 
7.1 - Attachment to Letter for Provider Site Reviews 
7.2  Sample Letter  Request for Medical Records 
7.3  Part A Sample Letter Notifying the Provider of the Results, and Request Repayment 
of Overpayments 
7.3.1  Attachment to the Part A Letter Notifying the Provider of the Results, and 
Request Repayment of Overpayments 
7.4  Part B Sample Letter Notifying the Provider of the Results, and Request Repayment 
of Overpayments 
7.4.1  Attachment to the Part B Letter Notifying the Provider of the Results, and 
Request Repayment of Overpayments 
8  Victimized Provider Process Letter Templates 
9 - Projection Methodologies and Instructions for Reviews of Home Health Agencies for Claims 
Not Paid Under PPS 
10 - Projection Methodologies and Instructions for Reviews of Skilled Nursing Facilities (SNFs) 
for Claims Not Paid Under PPS 
11 - Projection Methodologies and Instructions for Reviews of Comprehensive Outpatient 
Rehabilitation Facilities (CORFS) for Claims Not Paid Under PPS 
12 - Projection Methodologies and Instructions for Reviews of Community Mental Health 
Centers (CMHCs) for Claims Not Paid Under PPS 
13 - Postpayment  CMR Summary Report Format Example 
13.1  Excluded Providers 
14 - Contractor Denials 1862(a)(1) of the Act 
14.1 - Section 1879 of the Act Determination - Limitation of Liability 
14.2 - Section 1870 of the Act Determination - Waiver of Recovery of an Overpayment 
14.3 - Section 1842(l) of the Act Determination - Refunds to Beneficiary 
14.4  Effect of Sections 1879 and 1870 of the Social Security Act During Postpayment 
Reviews  15 - Consent Settlement Documents 
16 - Model Payment Suspension Letters 
16.1 - Referral Fact Sheet Format Template 
17  Signature Attestation Form (for missing or illegible signatures) 
18  Corrective Action Reporting Formats 
19  Reserved for Future Use 
20  Reserved for Future Use 
21 - Regional Home Health Intermediaries/Jurisdictions 
22 - Office of Inspector General, Office of Investigations Field Offices 
23 - PIM Acronyms 
25  Procedures and Forms for Obtaining Protected Health Information 
26 - DOJ Report (Excel Spreadsheet) 
27 - National Medicare Fraud Alert 
28 - Restricted Medicare Fraud Alert 
29 - Reserved for Future Use 
30 - Treatment Codes 
31 - Form CMS-485, Home Health Certification and Plan of Care 
32 - Harkin Grantee Winframe Database Access and Operation Instructions 
33 - Harkin Grantee Model Form 
34  Reserved for Future Use 
35  Memorandum of Understanding (MOU) with Law Enforcement 
36  Overview of the CERT Process 
36.1  CERT Formats for A/B MAC (A) MACS and Shared Systems 
36.2  CERT Formats for A/B MACs (B) and DME MACs and Shared Systems 
37  Federal Agreement (Office of the Inspector General) for Release of Data with Individual 
Identifiers 
38  Qualified Independent Contractor (QIC) Jurisdictions (as of March 2005) 
39 - Carrier Record Requirements 
40 - UPIN Carrier Record Layout 
40.1 - Trailer Record Data Elements 
41 - List of Medical School Codes 
41.1 - List of Medical School in the U.S. 
41.2 - Directory of Podiatric Medical Colleges 
41.3 - American Optometric Association Council on Optometric Education 
41.4 - List of Chiropractic Schools in the U.S. 
42 - Sanction Codes 
43 - Exhibit 5 
Exhibit 44  JOA Appendices 
  44.1  SMRC  UPIC JOA  
Exhibit 45  UPIC Prepayment and Postpayment Notification Letter 
Exhibit 46 - Unified Postpayment ADR Sample Letters  
46.1 - MAC Unified Postpayment ADR Sample Letter 
46.2 - DME MAC Unified Post-Payment ADR Sample Letter 
46.3  Recovery Audit Contractor (RAC) Unified Postpayment ADR Sample Letter  
46.4  CERT Unified Post-payment ADR Sample Letter 
46.5  SMRC Unified Postpayment ADR Sample Letter 
Exhibit 47  Program Integrity Unit Contacts within the State Medicaid Agency 
     
 
Exhibit 1 - Definitions 
(Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
A 
Abuse 
 
Billing Medicare for services that are not covered or are not correctly coded. 
 
Affiliated Contractor (AC) 
 
A Medicare carrier, Fiscal Intermediary (FI), or other contractor such as a Durable Medical 
Equipment Medicare Administrative Contractor (DME MAC), which shares some or all of the 
Unified Program Integrity Contractors (UPICs) jurisdiction; Affiliated Contractors perform 
non-UPIC Medicare functions such as claims processing. 
 
B-C 
Carrier 
 
The Carrier is an entity that has entered into a contract with CMS to process 
Medicare claims under Part B for non-facility providers (e.g., physicians, 
suppliers, laboratories). DME MACs are those carriers that CMS has designated 
to process DME, prosthetic, orthotic and supply claims. 
 
Case 
 
A case exists when the UPIC or Medicare contractor BI unit has referred a fraud allegation to 
law enforcement, including but not limited to, documented allegations that: a provider, 
beneficiary, supplier, or other subject has a) engaged in a pattern of improper billing, b) 
submitted improper claims with actual knowledge of their truth or falsity, or c) submitted 
improper claims with reckless disregard or deliberate ignorance of their truth or falsity. 
 
Contractor 
 
Contractor includes all intermediaries, carriers, DME MAC, RHHIs, MACs, and UPICs.  
 
Centers for Medicare & Medicaid Services (CMS) 
 
CMS administers the Medicare program. CMS responsibilities include management of AC and 
Medicare contractor claims payment, managing UPIC, AC, and Medicare contractor fiscal audit 
and/or overpayment prevention and recovery, and the development and the monitoring of 
payment safeguards necessary to detect and respond to payment errors or abusive patterns of 
service delivery. CMS was formerly known as the Health Care Financing Administration 
(HCFA). 
 
Closed Case 
 
A FID case shall be closed when no further action will be required of the UPIC, or Medicare 
contractor BI unit by the law enforcement agency(ies) working the case and when the law  enforcement agency(ies) has ended all its activity on the case. Note that even after the case is 
closed, there may still be administrative actions that the UPIC, or Medicare contractor BI unit 
will take. 
 
D-E 
 
Department of Justice (DOJ) 
 
Attorneys from DOJ and United States Attorneys Offices have criminal and 
civil authority to prosecute those providers who de-fraud the Medicare program. 
 
Demand Bill or Demand Claim 
 
A demand bill or demand claim is a complete, processable claim that must be submitted 
promptly to Medicare by the physician, supplier or provider at the timely request of the 
beneficiary, the beneficiarys representative, or, in the case of a beneficiary dually entitled to 
Medicare and Medicaid, a state as the beneficiarys subrogee. A demand bill or demand claim is 
requested usually, but not necessarily, pursuant to notification of the beneficiary (or 
representative or subrogee) of the fact that the physician, supplier or provider expects Medicare 
to deny payment of the claim. When the beneficiary (or representative or subrogee) selects an 
option on an advance beneficiary notice that includes a request that a claim be submitted to 
Medicare, no further demand is necessary; a demand bill or claim must be submitted. 
 
F 
 
Federal Bureau of Investigation (FBI) 
 
Along with OIG, the FBI investigates potential health care fraud. Under a special memorandum 
of understanding, the FBI has direct access to contractor data and other records to the same 
extent as OIG. 
 
Fraud 
 
Fraud is the intentional deception or misrepresentation that the individual knows to be false or 
does not believe to be true, and the individual makes knowing that the deception could result in 
some unauthorized benefit to himself/herself or some other person. 
 
G-H 
 
I 
 
Intermediary 
 
The intermediary is a public or private agency or organization that has entered into an agreement 
with CMS to process Medicare claims under both Part A and Part B for institutional providers 
(e.g., hospitals, SNFs, HHAs, hospices, CORFs, OPT, occupational therapy, speech pathology 
providers, and ESRD facilities). Regional home health intermediaries (RHHIs) are those FIs that 
CMS has designated to process Medicare claims received from home health and hospice 
providers. 
 
J-K-L 
Local Coverage Determinations (LCDs)   
The LCDs are those policies used to make coverage and coding decisions in the absence of 
specific statute, regulations, national coverage policy, national coding policy, or as an adjunct to 
a national coverage policy. 
 
M 
 
Medicare Contractor (Benefit Integrity) 
 
Medicare contractors include all intermediaries and carriers that have not transitioned their 
benefit integrity work to a UPIC. 
 
Medicare Contractor (Medical Review) 
 
Medicare contractors include intermediaries, carriers and MACs.  
 
Misrepresented 
 
A deliberate false statement made, or caused to be made, that is material to entitlement or 
payment under the Medicare program. 
 
N 
 
Noncovered (Not Covered) 
 
Noncovered services are those for which there is no benefit category, services that are statutorily 
excluded (other than 1862 (A)(1)(a)), or services that are not reasonable and necessary under 
1862 (A)(1)(a). 
 
O 
 
Office of Audit Services (OAS) 
 
The OAS conducts comprehensive audits to promote economy and efficiency and to prevent and 
detect fraud, abuse, and waste in operations and programs. OAS may request data for use in 
auditing aspects of Medicare and other Health and Human Service (HHS) programs and is often 
involved in assisting OIG/OI in its role in investigations and prosecutions. 
 
Office of Counsel to the Inspector General (OCIG) 
 
The OCIG is responsible for coordinating activities that result in the negotiation and imposition 
of Civil Monetary Penalties (CMPs), assessments, and other program exclusions. It works with 
the Office of Investigations (OIG), Office of Audit Services (OAS), CMS, and other 
organizations in the development of health care fraud and exclusions cases. 
 
Office of Inspector General (OIG) 
 
The OIG investigates suspected fraud or abuse and performs audits and inspections of CMS 
programs. In carrying out its responsibilities, OIG may request information or assistance from 
CMS, its Unified Program Integrity Contractor (UPIC), Medicare contractors, and QIOs. OIG 
has access to CMS's files, records, and data as well as those of CMS'scontractors. OIG 
investigates fraud, develops cases, and has the authority to take action against individual health  care providers in the form of CMPs and program exclusion, and to refer cases to the DOJ for 
criminal or civil action. OIG concentrates its efforts in the following areas: 
 
  Conducting investigations of specific providers suspected of fraud, 
waste, or abuse for purposes of determining whether criminal, 
civil, or administrative remedies are warranted; 
  Conducting audits, special analyses and reviews for purposes of 
discovering and documenting Medicare and Medicaid policy and 
procedural weaknesses contributing to fraud, waste, or abuse, and 
making recommendations for corrections; 
  Conducting reviews and special projects to determine the level of 
effort and performance in health provider fraud and abuse control; 
  Participating in a program of external communications to 
inform the health care community, the Congress, other 
interested organizations, and the public of OIG's concerns and 
activities related to health care financing integrity; 
  Collecting and analyzing Medicare contractor, AC, Medicare 
contractor, and State Medicaid agency-produced information 
on resources and results; and, 
  Participating with other government agencies and private health 
insurers in special programs to share techniques and knowledge on 
preventing health care provider fraud and abuse.  
 
Office of Investigations (OI) 
 
The Office of Investigations (OI), within OIG, is staffed with professional criminal investigators 
and is responsible for all HHS criminal investigations, including Medicare fraud. OIG/OI 
investigates allegations of fraud or abuse whether committed by UPICs, ACs, Medicare 
contractors, grantees, beneficiaries, or providers of service (e.g., fraud allegations involving 
physicians and other providers, contract fraud, and cost report fraud claimed by hospitals). 
 
The OIG/OI presents cases to the United States Attorney's Office within the Department of 
Justice (DOJ) for civil or criminal prosecution. When a practitioner or other person is determined 
to have failed to comply with its obligations in a substantial number of cases or to have grossly 
and flagrantly violated any obligation in one or more instances, OIG/OI may refer the case to 
OCIG for consideration of one or both of the following sanctions: 
 
  An exclusion from participation in the Medicare program or 
any State health care programs as defined under 1128(h) of 
the Social Security Act (the Act); or 
  The imposition of a monetary penalty as a condition to continued 
participation in the Medicare program and State health care 
programs. 
 
Offset 
 
The recovery by Medicare of a non-Medicare debt by reducing present or future Medicare 
payments and applying the amount withheld to the indebtedness. 
 
P 
 
Providers   
Any Medicare provider (e.g., hospital, skilled nursing facility, home health agency, outpatient 
physical therapy, comprehensive outpatient rehabilitation facility, renal dialysis facility, hospice, 
physician, non-physician practitioner, laboratory, supplier, etc.). For purposes of this manual, the 
term provider is generally used to refer to individuals or organizations that bill carriers, 
intermediaries, DME MACs, and RHHIs. If references apply to only specific providers (e.g., 
physicians), the specific provider will be identified. 
 
Q- R 
 
Quality Improvement Organization (QIO) 
 
The Peer Review Improvement Act of 1982 established the utilization and quality control peer 
review organization (PRO) program. The PRO name has changed to quality improvement 
organization. CMS contracts with independent physician organizations in each state to 
administer the QIO program. Their purpose is to ensure that the provisions of the Peer Review 
Improvement Act of 1982 are met. Under their contracts with CMS, QIOs are required to 
perform quality of care reviews of the medical services provided to Medicare beneficiaries in 
settings including, but not limited to: physician offices, acute care hospitals, specialty hospitals 
(for example psychiatric and rehabilitation hospitals), and ambulatory surgical centers. In the 
inpatient setting, QIOs also perform provider-requested higher-weighted DRG reviews for acute 
inpatient prospective payment system (IPPS) hospitals and long-term care hospital (LTCH) 
claims. 
 
Recoupment 
 
The recovery by Medicare of any outstanding Medicare debt by reducing present or future 
Medicare payments and applying the amount withheld to the indebtedness. 
 
Reliable Information 
 
Reliable information includes credible allegations, oral or written, and/or other material facts that 
would likely cause a non-interested third party to think that there is a reasonable basis for 
believing that a certain set of facts exists, for example, that claims are or were false or were 
submitted for non-covered or miscoded services. Reliable information of fraud exists if the 
following elements are found: 
 
  The allegation is made by a credible person or source. The source is 
knowledgeable and in a position to know.  The source experienced or 
learned of the alleged act first hand, i.e., saw it, heard it, read it. The 
source is more credible if the source has nothing to gain by not being 
truthful. The source is competent; e.g., a beneficiary may not always 
be a credible source in stating that services received were not 
medically necessary. An employee of a provider who holds a key 
management position and who continues to work for the provider is 
often a highly credible source. The friend of a beneficiary who heard 
that the provider is defrauding Medicare may not be a particularly 
credible source; 
  The information is material. The information supports the allegation 
that fraud has been committed by making it more plausible, 
reasonable, and probable (e.g., instructions handwritten by the 
provider delineating how to falsify claim forms).    The act alleged is not likely the result of an accident or honest 
mistake. For example, the provider was already educated on the 
proper way to complete the form, or the provider should know that 
billing for a service not performed is inappropriate, or claims are 
submitted the same way over a period of time by different employees. 
 
Reliable evidence includes but is not limited to the following: 
 
  Documented allegations from credible sources that items or services 
were not furnished or received as billed; 
  Billing patterns so aberrant from the norm that they bring into 
question the correctness of the payments made or about to be made; 
  Data analysis that shows the provider's utilization to be well 
above that of its peers without any apparent legitimate rationale 
for this; 
  Statements by beneficiaries and/or their families attesting to the 
provider's fraudulent behavior; 
  Corroboration from provider employees (official and unofficial whistle blowers); 
  Other sources, such as prepayment and postpayment review of medical records; or 
  Recommendations for suspension by OIG/OI, FBI, Assistant U.S. 
Attorneys (AUSAs), or CMS, based on their finding that the provider 
has already received overpayments and continued payments should be 
made only after a determination that continued payment is 
appropriate. 
 
S 
 
Services 
 
Medical care, items, such as medical diagnosis and treatment, drugs and biologicals, supplies, 
appliances, and equipment, medical social services, and use of hospital RPCH or SNF facilities. 
(42CFR 400.202). In other sections of Medicare manuals and remittance advice records, the term 
item/service is used. However, throughout this manual we will use the term service to be 
inclusive of item/service. See 1861 of Title 18 for a complete description of services by each 
provider type. 
 
Suspension of Payment 
 
Suspension of payment is defined in the regulation 42CFR 405.370 as "the withholding of 
payment by the carrier or intermediary from a provider or supplier of an approved Medicare 
payment amount before a determination of the amount of overpayment exists." In other words, 
ACs or Medicare contractors have received processed and approved claims for a provider's items 
or services; however, the provider has not been paid and the amount of the overpayment has not 
been established. 
 
T-U-V-W-X 
 
Unified Program Integrity Contractor (UPIC) 
 
The UPIC is a contractor dedicated to program integrity that handles such functions as audit, 
medical review and potential fraud and abuse investigations consolidated into a single contract. 
  T-U-V-W-X 
 
Exhibit 2  Reserved for Future Use 
(Rev. 220, Issued: 08-24-07, Effective: 09-03-07, Implementation: 09-03-07) 
 
 
 
 
Exhibit 4 - Reliable Information - (Rev. 3, 11-22-00) 
 
Reliable evidence includes but is not limited to the following: 
  Documented allegations from credible sources that items or services were not furnished 
or received as billed;  
  Billing patterns so aberrant from the norm that they bring into question the correctness of 
the payments made or about to be made;  
  Data analysis that shows the provider's utilization to be well above that of its peers 
without any apparent legitimate rationale for this;  
  Statements by beneficiaries and/or their families attesting to the provider's fraudulent 
behavior;  
  Corroboration from provider employees (official and unofficial whistle blowers);  
  Other sources, such as prepayment and postpayment review of medical records; or  
  Recommendations for suspension by OIG/OI, FBI, Assistant U.S. Attorneys (AUSAs), or 
CMS, based on their finding that the provider has already received overpayments and 
continued payments should be made only after a determination that continued payment is 
appropriate.  
Exhibit 5 - Background Information When IRP is Questioned - (Rev. 3, 11-22-
00) 
 
Section 203(b)(1) of the Health Insurance Portability and Accountability Act of 1996 allows the 
federal government to pay a reward to individuals who report evidence of suspected fraud and 
abuse against the Medicare program.  Implementing regulations, issued on June 8, 1998, were 
effective on July 8, 1998 and provide that a complainant may be rewarded up to 10 percent of the 
amount recovered, but not more than $1,000.  Not everyone is eligible for the reward, 
though.  To be eligible for a reward: 
  The information you give has to lead to a recovery of at least $100;  
  The suspected fraud must be acts or omissions that are grounds for the government to 
impose sanctions provided under certain provisions of the law;  
  There isn't another reward that you qualify for under another government program;  
  You must not have participated in the sanctionable offense with respect to which 
payment is being made;  
  If the person or organization is already under investigation; and     You are not an immediate family member or an employee of the Department of Health 
and Human Services, its contractors or subcontractors, the Social Security 
Administration, the Office of the Inspector General, a State Medicaid agency, the 
Department of Justice, the FBI, or any other federal, State, or local law enforcement 
agency at the time he or she came into possession, or divulged information leading to a 
recovery of Medicare funds.  
You'll receive a letter from us acknowledging that we have received your complaint.  Some 
investigations take a long time to complete, and may take several months or years to 
resolve.  You'll be notified by letter of your eligibility to receive a reward after the Medicare 
funds have been recovered.  If you do receive a reward for this information you may be expected 
to pay any applicable state and federal taxes. 
5.1 - Reward Eligibility Notification Letter - (Rev. 3, 11-22-00) 
 
 Dear________________________________: 
You are eligible for a reward as part of the Medicare Incentive Reward Program for telling us 
about Medicare fraud and abuse. 
To claim your reward, please fill out the enclosed form and return it to [contractor information] 
in the enclosed envelope. You have one year from the date of this letter to claim your reward. 
In the case of death or incapacitation of the person reporting the potential fraud, a legal 
representative of that person may claim the reward on his or her behalf when evidence is 
submitted to justify the claim. 
If it is later found that you received the reward caused by your misrepresentation of the facts, all 
monies paid to you must be returned to Medicare. If you have questions, please contact 
[contractor information]. 
Sincerely, 
[Contractor Information] 
Enclosures 
5.2 - Reward Claim Form - (Rev. 3, 11-22-00) 
 
[To be completed by contractor.] 
Provider/Supplier Name 
Case Number 
REWARD CLAIM FORM 
 
Date  Dear [Contractor Information]: 
I am claiming the reward for providing information about Medicare fraud by filling out this form 
as it applies to me.  My signature verifies that I am a proper recipient of the incentive reward or 
that I am the legal representative of the proper recipient of the reward.  I also understand that the 
reward must be repaid by the recipient if it is later determined that the reward should not have 
been received. 
CLAIMANT INFORMATION 
Name________________________________________________ 
                                                                   
Street Address______________________________________ 
City, State, Zip code______________________________ 
                                                                       
Telephone Number____________________________________ 
Claimant (or Representative) Signature__________________________ 
REPRESENTATIVE INFORMATION 
If the intended recipient of the reward has become incapacitated or has died, his or her executor, 
administrator, or other legal representative may collect the reward on the individual's behalf or 
for the individual's estate. In addition to submitting this letter, please also submit certified copies 
of letters testamentary, letters of administration, or other similar evidence to show your authority 
to claim the reward. In the space provided below, please submit your name and the mailing 
address where the check should be sent if that address differs from the information stated above. 
Name________________________________________________ 
                                                                   
Street Address______________________________________ 
City, State, Zip code______________________________ 
                                                                       
Telephone Number____________________________________ 
  
5.3 - How to Use the IRP Tracking System - (Rev. 3, 11-22-00) 
  Selected IRP screen exhibits may be viewed from the PIM whenever "Click here to view the 
selected screen" is indicated in bold. 
After you log on to the Winframe, you will see the IRP Tracking group icon.  Double click on 
that icon, then double click on the IRP Tracking to run the application. The first screen IRP 
Menu will appear. 
Click here to view an exhibit of the IRP Menu screen. 
A.  Screen Use 
From the IRP menu screen, click on the item you would like to select.  Reference 5.4 through 
5.9 below for explicit instructions on how to use every menu option of the IRP system. 
B.  Options 
  1.   Pending Case List - This function allows you to view all of the pending cases in the 
system. See 5.4 below for details on this option. 
  2.   Pending List By Contractor  - This function allows you to view all of the pending 
cases that are listed by each contractor ID number.  See 5.5 below for details on this option. 
  3.   New Case - This function allows you to enter a new case into the system.  See 5.6 
below for details on this option. 
  4.   Closed Case List - This function allows you to view all of the closed cases in the 
system.  See 5.7 below for details on this option. 
  5.   Closed Case List By Contractor - This function allows you to view all of the closed 
cases that are listed by each contractor's ID number. See 5.8 below for details on this option. 
  6.   Report Menu - This function allows you to open the report menu that contains all 
available predefined reports. 
5.4 - Section I: Pending Case List Screen - (Rev. 3, 11-22-00) 
 
Click here to view an exhibit of the Pending Case List Screen. 
View Case- After you select a case number, you can double click on the view case button on the 
bottom of the screen to view the case detail screen of the case selected. From the case detail 
screen you may: 
1.  View Comments 
You may enter/edit contractor comments or view CMS comments.  DO NOT EDIT CMS 
COMMENTS. You may save comments or save/close form. 
2.  Edit Case  You may select view/edit comments and enter/edit contractor comments or view CMS 
comments.  DO NOT EDIT CMS COMMENTS.  You may save comments or save/close 
form.  You may also select enter/edit provider to access the provider detail screen.  From the 
provider detail screen you may click on 1) add new provider; 2) delete provider; 3) edit provider; 
or 4) enter/edit an allegation against a provider.  To edit the provider appearing on the screen, 
click on the edit provider button.  You may click on next provider or previous provider to find 
the one that you want to edit.  To enter/edit an allegation, click on the allegation button to get to 
the view allegations screen. Select the case desired and you may add or delete an allegation or 
cancel this function. 
3.  View Report 
Click on the view report to get to the case report menu.  You may now view the details of the 
selected case. 
5.5 - Section II: Pending Case List by Contractor Screen - (Rev. 3, 11-22-00) 
 
You may perform the same functions as in 5.4 (I) above: Pending Case List. However, 
information will be provided specific to the contractor ID number entered. 
5.6 - Section III: New Case - (Rev. 3, 11-22-00) 
 
Click here to view an exhibit of the New Case Screen. 
Click on the new case button to get the new case screen.  You must enter a FID number at this 
time to enter new case information. You can move from one data field to another by either using 
the Tab key or the mouse to move the cursor to that data field.  After entering all available 
information, you must remember to click on the enter provider information to access the provider 
detail screen and click on the enter complainant information to access the complainant detail 
screen.  You may also edit the provider information or complainant information using this same 
approach.  If the provider number is not entered at this time, the system will not allow you to 
save this provider information.  The case number and complainant's first, middle initial and last 
name must be entered to allow you to save the complainants information. 
1.  Provider Detail - Enter provider information. Click the enter allegation button to get to the 
view allegations screen.  At this point, you may add an allegation, delete an allegation, or 
cancel the screen.  An allegation is added by typing in an allegation code next to the provider 
number and then clicking on "OK".  You may exit the screen by clicking on the ok-save edits 
button. 
2.  Complainant Detail - Enter complainant information, and then close screen. 
5.7 - Section IV: Closed Case List - Rev.) 
 
Click here to view an exhibit of the Closed Case List Screen. 
You may perform the same functions as in 5.4 (I) above, however, pending case list information 
will be provided only for closed cases.  5.8 - Section V: Closed Case List by Contractor - (Rev. 3, 11-22-00) 
 
You may perform the same functions as in 5.5 (II) above: Pending case list by contractor 
however, information will be provided for closed cases specific to the contractor ID number 
entered. 
5.9 - Section VI: Report Menu - (Rev. 3, 11-22-00) 
 
Click here to view an exhibit of the Report Menu Screen. 
Click here to view an exhibit of the IRP Cases List Screen. 
Click here to view an exhibit of the View Case Detail Screen. 
Click here to view an exhibit of the Edit Case Detail Screen. 
Click here to view an exhibit of the Comments Screen. 
Click here to view an exhibit of the Provider Detail Screen. 
Click here to view an exhibit of the Provider Edit Detail Screen. 
Click here to view an exhibit of the View Allegations Screen. 
Click here to view an exhibit of the View Edit Allegations Screen. 
Click here to view an exhibit of the View Complainant Detail Screen. 
Click here to view an exhibit of the Case Report Screen. 
The report menu provides a variety of management reports in brief format and detailed 
format.  Click on the report menu from the main IRP menu. Select the type of report desired 
from the following list: 
A.   Brief List 
  All Cases;  
  Pending Cases;  
  Closed Cases;  
  Rewarded Cases;  
  Recovery From Ten Thousand Up; and  
  Notified But Not Rewarded  
B.   Detail List 
  All Cases   C.  List By Contractor 
  All Cases- Brief; and  
  All Cases- Detailed  
 
EXHIBITS 
 
Exhibit 7 - Sample Letter for On-Site Reviews  
(Rev. 213, Issued: 06-29-07, Effective: 07-30-07, Implementation: 07-30-07) 
 
DATE: 
 
PROVIDER NAME:  CONTRACTOR NAME: 
PROVIDER  CONTRACTOR ADDRESS: 
ADDRESS: 
   
OPENING   
 
Dear _______: 
 
Thank you for your cooperation during the comprehensive medical review conducted at your 
facility on ___________.  Based on this review we have determined that you have been 
overpaid.  We hope the following information answers any questions you may have. 
 
REASON FOR REVIEW 
 
This review was conducted because our analysis of your billing data showed that your facility 
utilized ________ services at a rate of 50 percent more than that of your peer group. 
 
HOW THE OVERPAYMENT WAS DETERMINED 
 
A random sample of ________ claims processed from 01/01/98 to 06/30/98 was selected for 
review to determine if the services billed were reasonable and necessary and that all other 
requirements for Medicare coverage were met. Medical documentation for the selected claims 
was reviewed by our medical review staff. 
 
Our review found that some services you submitted were not reasonable and necessary as 
required by the Medicare statute or did not meet other Medicare coverage requirements. 
 
WHY YOU ARE RESPONSIBLE 
 
You are responsible for the overpayment if you knew or had reason to know that service(s) were 
not reasonable or necessary, and/or you did not follow correct procedures or use care in billing or 
receiving payment. 
  The attachment identifies the specific claims that have been determined to be fully or partially 
non-covered, the specific reasons for denial, an explanation of why you are responsible for the 
incorrect payment and the amount of the overpayment. 
 
WHAT YOU SHOULD DO 
 
Please return the amount of the overpayment to us by ________ and no interest charge will be 
assessed. Make the check payable to Medicare Part A and send it with a copy of this letter to: 
 
Intermediary's Address 
 
IF YOU DO NOT REFUND WITHIN 30 DAYS: 
 
If you repay the overpayment within 30 days, you will not have to pay any interest charge. 
 
However, if you do not repay the amount within 30 days, interest will accrue from the date of 
this letter at the rate of _____ percent for each full 30-day period that payment is not made on 
time. 
 
On ________ we will automatically begin to recoup the overpayment amount against your 
pending claims. Recouped payments will be applied to the accrued interest first and then to the 
principal. If you believe that recoupment should not be put into effect, submit a Statement within 
15 days of the date of this letter to the above address, giving the reason(s) why you feel this 
action should not be taken.  We will review your documentation.  However, this is not an appeal 
of the overpayment determination, and it will not delay recoupment. 
 
For copies of the applicable laws and regulations, please contact us at the address shown in our 
letterhead, to the attention of the __________ Department. 
 
APPEAL RIGHTS: 
 
If you disagree with the overpayment decision, you may file an appeal.  An appeal is a review 
performed by people independent of those who have reviewed your claim so far.  The first level 
of appeal is called a redetermination.  You must file your request for a redetermination within 
120 days of the date you receive this letter.  Unless you show us otherwise, we assume you 
received this letter 5 days after the date of this letter.  Please send your request for a 
redetermination to: 
 
Address to which redetermination request should be sent 
 
GENERAL PROBLEMS IDENTIFIED IN THE REVIEW AND/OR CORRECTIVE ACTIONS 
TO BE TAKEN 
 
This review has shown that you are not following national Medicare guidelines in submitting 
claims for necessary and reasonable ________ services.  In addition, you have not followed the 
Provider Bulletins and letters sent to you regarding local medical review policies and specific 
problems that we have identified with your billing practices.  Your future claims for _______ 
will be suspended for prepayment review until you correct your billing. 
 
If you have any questions regarding this matter, please contact _________ at ___________. 
 
Thank you in advance for your prompt attention to this matter.   
Sincerely, 
 
7.1 - Attachment to Letter for Provider Site Reviews - (Rev. 3, 11-22-00) 
Following is a list of the claims denied as a result of the review: 
  Beneficiary Name: John Smith  
  HI Claim Number: 000-00-0000 A  
  Service Dates: 12/08/97 - 12/08/97  
  Services Denied and Dates: Magnetic Resonance Imaging (MRI) 12/08/97  
  Reason for Denial: MRI's are not considered reasonable and medically necessary for the 
diagnosis of xxxx.  
  Why the Provider is Responsible: We believe you knew or should have known that the 
services were not reasonable and necessary because you were notified in a Provider 
Bulletin.  The Bulletin dated April 1, 1997, outlined Local Medical Review Policy which 
indicated that MRI's were not covered for the diagnosis of xxxx. Therefore, you are 
responsible for paying the overpayment amount.  
  Overpayment: $900.00  
  Beneficiary Name: Mary Smith  
  HI Claim Number: 000-00-0000B  
  Service Dates: 10/01/97 - 10/31/97  
  Services Denied and Dates: Physical therapy evaluation and re-evaluation on 10/03/97 
and 10/26/97.  
  Reason for Denial: The two physical therapy visits are not reasonable and medically 
necessary because the medical documentation shows that the patient was ambulatory and 
had no functional problems which would have required a physical therapy evaluation or 
re-evaluation.  
  Why you are Responsible: In a letter dated 07/30/97 you were notified that such therapy 
evaluation and re-evaluation were not considered reasonable and necessary. Therefore, 
you are responsible for the overpayment.  
  Overpayment: $ 200.00  
  Beneficiary Name: Tom Jones  
  HI Claim Number: 000-00-0000A  
  Service Dates: 12/10/97 - 12/31/97  
  Services Denied and Dates: 10 physical therapy visits from 12/10/97 - 12/31/97  
  Reason for Denial: No plan of care signed by a physician.     Why you are responsible: We find you responsible for the overpayment because 
regulations at 42 CFR, and manual instructions at xxxx, clearly require a plan of care 
signed by a physician for therapy visits.  
  Overpayment: $1,200.00  
 
7.2 - Exhibit-Sample Letter--Request For Medical Records - (Rev.           ) 
 
The intermediary uses the following letter to request necessary medical records from the 
provider. 
DATE: 
                     
PROVIDER NAME:  INTERMEDIARY NAME: 
PROVIDER ADDRESS:  INTERMEDIARY ADDRESS: 
PROVIDER NUMBER:    
OPENING: 
Dear XXXXX: 
You have been selected for a comprehensive medical review (CMR) of your billing for Medicare 
services pursuant to CMSs statutory and regulatory authority.  You were selected for this review 
because our analysis of your billing data indicates that you may be billing inappropriately for 
services. 
We have selected a random sample of ___ claims for services provided during the period _____ 
through _____.  (See attached listing.)  For each of these claims, we are requesting the following 
information: 
[The following list is for illustrative purposes.  MR should request any documentation that will 
permit them to conduct a thorough review of the claims submitted with regard to coverage, 
eligibility, medical reasonableness and necessity, limitation on liability determinations (1879), 
without fault determinations (1870), etc.] 
  Form HCFA-485;  
  Form HCFA-486, or equivalent information, if applicable;  
  Form HCFA-487, or equivalent information, if applicable;  
  Flow sheets or treatment sheets, if used;  
  Narrative or progress notes, if used;  
  Supplemental order, if applicable;  
  Itemized breakdown of supplies, if supplies are billed;  
  Lab values, if applicable;  
  Copy of the UB-92 for each bill;     Lab reports for any B12 injections;  
  Lab or x-ray reports for any calcimar injection;  
  Other __________________________________________  
The above information should be mailed to the following address within 30 days from the date of 
this letter: 
Intermediary Name, Address, and Contact Person 
Our medical review staff will review the documentation you submit for each of the claims to 
determine if the services billed are reasonable and necessary and meet all other requirements for 
Medicare coverage.  Along with our claims payment determination, we will make a limitation on 
liability decision for services that are subject to the provisions of 1879 of the Social Security 
Act  (the Act), and a determination in accordance with 1870 of the Act (whether you are 
without fault for any overpayments). 
We will project the overpayments identified in the sample to the universe of claims processed 
during the time frame described above.  We will adjust the projected overpayment to reflect 
any previously denied claims which are payable, denied claims for which you were found not 
liable under 1879 of the Act, and denied claims for which you were found to be without fault 
under 1870 of the Act.  
Following our review, we will inform you in writing of our findings.  We will provide you with a 
listing of the claims that were reviewed and our determinations with regard to those claims (i.e., 
full or partial denials and payable claims), the specific reasons for denial, identification of 
denials that fall under 1879 of the Act and those that do not, our liability determination for 
those denials that fall under 1879 of the Act, our determination of whether you are without fault 
under 1870 of the Act, an explanation of why you are responsible for the incorrect payment, the 
amount of the overpayment or underpayment, and interest accrual on unpaid balances.  We will 
provide you with an explanation of your right to submit a rebuttal statement under 42 CFR 
405.370-375 if we determine that you have been overpaid, and your options for repaying any 
overpayments, or our refund of any underpayments.  We will provide you with an explanation of 
how any overpayment was determined, including the sampling methodology used to project the 
amount of the overpayment.  We will also provide you with a full explanation of your appeal 
rights, including appeal of the sampling methodology used to determine the overpayment, 
estimation of the overpayment, coverage decisions, limitation on liability decisions under 1879 
of the Act, and our determination as to whether you are without fault under 1870 of the Act.  
If you have any questions concerning this request, you may contact me at (telephone 
number).  Your cooperation is appreciated. 
  Sincerely, 
Enclosure:  Listing of Sample Claims Requiring Medical Documentation 
7.3 - Exhibit: Part A Sample Letter Notifying the Provider of the Results, and 
Request Repayment of Overpayments 
(Rev. 213, Issued: 06-29-07, Effective: 07-30-07, Implementation: 07-30-07) 
 
DATE:   
PROVIDER NAME:  INTERMEDIARY NAME: 
PROVIDER ADDRESS:  INTERMEDIARY ADDRESS: 
PROVIDER NUMBER:   
 
OPENING: 
Dear XXXXXX: 
 
Thank you for your cooperation during the comprehensive medical review conducted at your 
facility on ___________.  Based on this review, we have reopened claims in accordance with the 
reopening procedures at 42 CFR 405.750 and have determined that you have been overpaid in 
the amount of ____________.  We hope the following information answers any questions you 
may have. 
 
REASON FOR REVIEW 
 
This review was conducted because our analysis of your billing data showed that you may be 
billing inappropriately for services. (Include in this paragraph any additional details on why the 
provider was selected for the review.) 
 
HOW THE OVERPAYMENT WAS DETERMINED 
 
A randomly selected sample of ________ claims processed from ________ to ________ was 
selected for review to determine if the services billed were reasonable and necessary and that all 
other requirements for Medicare coverage were met.  Medical documentation for the selected 
claims was reviewed by our medical review staff. 
 
Based on the medical documentation reviewed for the selected claims, we found that some 
services you submitted were not reasonable and necessary, as required by the Medicare statute, 
or did not meet other Medicare coverage requirements.  Along with our claims payment 
determination, we have made limitation on liability decisions for denials of those services subject 
to the provisions of 1879 of the Social Security Act (the Act).  Those claims for which we 
determined that you knew, or should have known, that the services were noncovered have been 
included in the results of this review.  In addition, we have made decisions as to whether or not 
you are without fault for the overpayment under the provisions of 1870 of the Act.  Those 
claims for which you are not without fault have been included in the results of this review.  We 
projected our findings from the claims that we reviewed to the universe of claims processed 
during the time frame mentioned above. 
 
TOTAL OVERPAYMENTS 
 
(List the aggregate overpayments) 
 
Be advised that this overpayment amount is based on your interim payment rate in effect at the 
time the review was done.  Further adjustments may be made when your cost report is settled. 
 
GENERAL PROBLEMS IDENTIFIED IN THE REVIEW AND/OR CORRECTIVE ACTIONS 
TO BE TAKEN 
 
This review has shown that you are not following published Medicare guidelines and policies in 
submitting claims for necessary and reasonable ________ services.  (Reference any provider  specific education that occurred regarding these services.)  Because of these identified problems, 
your future claims for _______ may be subject to prepayment review until you correct your 
billing. 
 
WHY YOU ARE RESPONSIBLE 
 
You are responsible for the overpayment if you knew or had reason to know that service(s) were 
not reasonable and necessary, and/or you did not follow correct procedures or use care in billing 
or receiving payment, and you are found to be not without fault under 1870 of the Act. 
 
A list of the specific claims that have been determined to be fully or partially noncovered, the 
specific reasons for denial, identification of denials that fall under 1879 of the Act and those 
that do not, the determination of whether you are without fault under 1870 of the Act, an 
explanation of why you are responsible for the incorrect payment, and the amount of the 
overpayment is attached.  (Enclose a list of the specific claims from the sample that have been 
found not to be covered.  See the example within this exhibit.) 
 
The sampling methodology used in selecting claims for review and the method of overpayment 
estimation is attached.  (Enclosed an explanation of the sampling methodology.) 
 
WHAT YOU SHOULD DO 
 
Please return the amount of the overpayment to us by (insert date, 15 days from date of 
letter).   However, you may request an extended repayment schedule in accordance with 42 CFR 
401.607(c).  Please contact (name of contact person at the FI/RHHI) on (phone number of 
contact person) to discuss repayment options for the full amount of the overpayment determined 
by the projection of errors found on the ___claim sample. 
 
INTEREST 
 
If you refund the overpayment within 30 days, you will not have to pay any interest charge.  If 
you do not repay the amount within 30 days, interest will accrue from the date of this letter at the 
rate of _____ percent for each full 30-day period that payment is not made on time.  Medicare 
charges interest on its outstanding Part A debts in accordance with 1815(d) of the Act and 42 
CFR 405.378. 
 
RECOUPMENT AND YOUR RIGHT TO SUBMIT A REBUTTAL STATEMENT 
 
As provided in regulations at 42 CFR 401.607(a) and 405.370-375, on (insert date provided in 
above paragraph captioned, "What You Should Do"), we will automatically begin to recoup the 
overpayment amount against your pending and future claims.  If you do not repay the debt within 
30 days, we will apply your payments, and amounts we recoup, first to accrued interest and then 
to principal.  Also, in accordance with the Debt Collection Improvement Act, we may refer your 
debt to the Department of Treasury for offset against any monies payable to you by the Federal 
Government. 
 
You have the right to submit a rebuttal Statement in writing within fifteen days from the date of 
this letter.  Your rebuttal Statement should address why the recoupment should not be put into 
effect on the date specified above.  You may include with this Statement any evidence you 
believe is pertinent to your reasons why the recoupment should not be put into effect on the date 
specified above.  Your rebuttal Statement and evidence should be sent to: 
  FI Name, Address, Telephone #, and Fax # 
 
Upon receipt of your rebuttal Statement and any supporting evidence, we will consider and 
determine within fifteen days whether the facts justify continuation, modification, or termination 
of the overpayment recoupment.  We will send you a separate written notice of our determination 
that will contain the rationale for our determination.  However, recoupment will not be delayed 
beyond the date Stated in this notice while we review your rebuttal Statement.  This is not an 
appeal of the overpayment determination, and it will not delay recoupment based on 1893(f)(2) 
of the Act.  If put into effect, the recoupment will remain in effect until the earliest of the 
following:  (1) the overpayment and any assessed interest are liquidated; (2) we obtain a 
satisfactory agreement from you to liquidate the overpayment; (3) a valid and timely appeal is 
received; or (4) on the basis of subsequently acquired evidence, we determine that there is no 
overpayment. 
 
If you choose not to submit a rebuttal Statement, the recoupment will automatically go into effect 
on (insert same date as provided in paragraph captioned, "What You Should Do ").  Whether or 
not you submit a rebuttal Statement, our decisions to recoup or delay recouping, to grant or 
refuse to grant an extended repayment schedule, and our response to any rebuttal Statement are 
not initial determinations as defined in 42 CFR 405.704, and thus, are not appealable 
determinations.  (See also, 42 CFR 401.625 and 405.375(c).) 
 
YOUR RIGHT TO CHALLENGE OUR DECISIONS 
 
This letter serves as our revised determination of the claims listed in the Attachment.  If you 
disagree with this determination, you may request a redetermination within 120 days of the date 
you receive this letter (unless you can show us otherwise, receipt is presumed to be five (5) days 
from the date of this letter).  You have the right to raise the same issues under this procedure as 
you would have in the context of non-sampling claims determinations under Part A and 
overpayment recovery.  (See 42 CFR 405.701, et seq.)  You may ask for a redetermination of the 
denials for which you are determined to be liable under 1879 of the Act or for which the 
beneficiary is determined to be liable under 1879 of the Act, but declined, in writing, to 
exercise his/her appeal rights, and determinations for which you are found to be not without fault 
under 1870 of the Act.  You may also challenge the validity of the sample selection and the 
validity of the statistical projection of the sample results to the universe.  (Refer to the appeals 
procedure in your Provider Manual  __________ for further details.) 
 
If you have any questions regarding this matter, please contact _________ at 
___________.  (Provide correspondence address.) 
 
Thank you in advance for your prompt attention to this matter. 
 
Sincerely, 
 
Enclosures 
 
7.3.1 - Exhibit: Attachment to the Part A Letter Notifying the Provider of the 
Results, and Request Repayment of Overpayments 
(Rev.) 
 
The following is a list of claims denied as a result of the review:  A.     Beneficiary Name:  John Smith 
  1.   HI Claim Number:  000-00-0000 A 
  2.   Service Dates:  12/01/96 - 01/15/97 
  3.   Services Denied and Dates:  45 Inpatient SNF Days, 12/1/96 - 1/15/97 
4.   Reason for Denial:  The therapy services rendered were not medically reasonable and 
necessary because they were for overall fitness and general well being and did not require the 
skills of a qualified physical therapist ( 1879 denial). (Provide details that led you to the 
conclusion that the services were non-skilled.) 
5.   Why You Are Responsible:  We find that you knew or should have known that 
payment would not be made for such items or services under Part A, and you are not without 
fault in accordance with 1870 of the Social Security Act.  We believe you knew or should have 
known that the services were not medically reasonable and necessary because of the educational 
contacts made in July 1996 and October 1996 regarding Medicare coverage of therapy 
services.  In these contacts numerous similar examples were cited as noncovered.  Therefore, you 
are responsible for paying the overpayment amount. 
  6. Overpayment:  $2,000.00 
 
B.     Beneficiary Name:  Mary Smith 
 
  1.   HI Claim Number:000-00-0000 B 
  2.   Service Dates:  01/01/97 - 01/31/97 
  3.   Services Denied and Dates:  31 Inpatient SNF Days, 01/01/97 - 01/31/97 
  4.   Reason for Denial:  There was no skilled care furnished on a daily basis.  Skilled 
therapy services were furnished 2-3 times a week, although therapy is available in your facility 
on a daily basis. 
  5.   Why You Are Responsible:  We find that you knew or should have known that 
payment would not be made for such items or services under Part A, and you are not without 
fault in accordance with 1870 of the Social Security Act.  The Medicare coverage guidelines in 
the SNF manual clearly state the requirement for daily skilled services.  You were also notified 
in educational contacts in July 1997 and October 1997 of similar cases.  Therefore, you are 
responsible for the overpayment. 
  6.   Overpayment:  $200.00 
7.4 - Exhibit: Part B Sample Letter Notifying the Provider of the Results, and 
Request Repayment of Overpayments 
(Rev. 213, Issued: 06-29-07, Effective: 07-30-07, Implementation: 07-30-07) 
 
SAMPLE LETTER--MEDICARE PART B 
  DATE: 
 
PROVIDER NAME:  INTERMEDIARY NAME: 
PROVIDER ADDRESS:  INTERMEDIARY ADDRESS: 
PROVIDER NUMBER:   
 
OPENING: 
Dear XXXXX: 
 
Thank you for your cooperation during the comprehensive medical review conducted at your 
facility on ___________.  Based on this review, we have reopened claims in accordance with the 
reopening procedures at 42 CFR 405.841 and have determined that you have been overpaid in 
the amount of ____________.  We hope the following information answers any questions you 
may have. 
 
REASON FOR REVIEW 
 
This review was conducted because our analysis of your billing data showed that you may be 
billing inappropriately for services. (Include in this paragraph any additional details on why the 
provider was selected for the review.) 
 
HOW THE OVERPAYMENT WAS DETERMINED 
 
A randomly selected sample of ________ claims processed from ________ to ________ was 
selected for review to determine if the services billed were reasonable and necessary and that all 
other requirements for Medicare coverage were met.  Medical documentation for the selected 
claims was reviewed by our medical review staff. 
 
Based on the medical documentation reviewed for the selected claims, we found that some 
services you submitted were not reasonable and necessary, as required by the Medicare statute, 
or did not meet other Medicare coverage requirements.  Along with our claims payment 
determination, we have made limitation on liability decisions for denials of those services subject 
to the provisions of 1879 of the Social Security Act (the Act).  Those claims for which we 
determined that you knew, or should have known, that the services were noncovered have been 
included in the results of this review.  In addition, we have made decisions as to whether or not 
you are without fault for the overpayment under the provisions of 1870 of the Act.  Those 
claims for which you are not without fault have been included in the results of this review.  We 
projected our findings from the claims that we reviewed to the universe of claims processed 
during the time frame mentioned above. 
 
GENERAL PROBLEMS IDENTIFIED IN THE REVIEW AND/OR CORRECTIVE ACTIONS 
TO BE TAKEN 
 
This review has shown that you are not following published Medicare guidelines and policies in 
submitting claims for necessary and reasonable ________ services.  (Reference any provider 
specific education that occurred regarding these services.)  Because of these identified problems, 
your future claims for _______ may be subject to prepayment review until you correct your 
billing. 
 
WHY YOU ARE RESPONSIBLE 
  You are responsible for the overpayment if you knew or had reason to know that service(s) were 
not reasonable and necessary, and/or you did not follow correct procedures or use care in billing 
or receiving payment, and you are found to be not without fault under 1870 of the Act. 
 
A list of specific claims that have been determined to be fully or partially noncovered, the 
specific reasons for denial, identification of denials that fall under 1879 of the Act and those 
that do not, the determination of whether you are without fault under 1870 of the Act, an 
explanation of why you are responsible for the incorrect payment, and the amount of the 
overpayment is attached.  (Enclosed a list of the specific claims and an explanation of fault for 
each.  See the example within this exhibit.) 
 
An explanation of the sampling methodology used in selecting claims for review and the method 
of overpayment estimation is attached.  (Enclose an explanation of the sampling methodology.) 
 
WHAT YOU SHOULD DO 
 
Please return the overpaid amount to us by _______________(date) and no interest charge will 
be assessed.  Make the check payable to Medicare Part B and send it with a copy of this letter to: 
 
__________________Address 
 
IF YOU DO NOT REFUND IN 30 DAYS 
 
In accordance with 42 CFR 405.378, simple interest at the rate of _______ will be charged on 
the unpaid balance of the overpayment beginning on the 31st day.  Interest is calculated in 30-day 
periods and is assessed for each full 30-day period that payment is not made on time.  Thus, if 
payment is received 31 days from the date of final determination, one 30-day period of interest 
will be charged.  Each payment will be applied first to accrued interest and then to principal.  
After each payment, interest will continue to accrue on the remaining principal balance at the 
rate of ______. 
 
We must request that you refund this amount in full.  If you are unable to make refund of the 
amount at this time, advise this office immediately so that we may determine if you are eligible 
for an extended repayment schedule.  (See enclosure for details.)  Any extended repayment 
schedule (where one is approved) would run from the date of this letter. 
 
RECOUPMENT AND YOUR RIGHT TO SUBMIT A REBUTTAL STATEMENT 
If payment in full is not received by (specify a date 40 days from the date of the notification), 
payments to you will be withheld until payment in full is received, an acceptable extended 
repayment request is received, or a valid and timely appeal is received. 
 
You have the right to submit a rebuttal Statement in writing within fifteen days from the date of 
this letter.  Your rebuttal Statement should address why the recoupment should not be put into 
effect on the date specified above.  You may include with this Statement any evidence you 
believe is pertinent to your reasons why the recoupment should not be put into effect on the date 
specified above.  Your rebuttal Statement and evidence should be sent to: 
 
Carrier Name, Address, Telephone #, and Fax # 
 
Upon receipt of your rebuttal Statement and any supporting evidence, we will consider and 
determine within 15 days whether the facts justify continuation, modification or termination of 
the overpayment recoupment.  We will send you a separate written notice of our determination  that will contain the rationale for our determination.  However, recoupment will not be delayed 
beyond the date Stated in this notice while we review your rebuttal Statement.  This is not an 
appeal of the overpayment determination, and it will not delay recoupment based on 1893(f)(2) 
of the Act.  If put into effect, the recoupment will remain in effect until the earliest of the 
following: (1) the overpayment and any assessed interest are liquidated; (2) we obtain a 
satisfactory agreement from you to liquidate the overpayment; (3) a valid and timely appeal is 
received; or (4) on the basis of subsequently acquired evidence, we determine that there is no 
overpayment. 
 
Whether or not you submit a rebuttal Statement, our decisions to recoup or delay recouping, to 
grant or refuse to grant an extended repayment schedule, and our response to any rebuttal 
Statement are not initial determinations as defined in 42 CFR 405.803, and thus, are not 
appealable determinations.  (See also, 42 CFR 401.625 and 405.375(c).) 
 
YOUR RIGHT TO CHALLENGE OUR DECISIONS 
 
This letter serves as our revised determination of the claims listed in the attachment.  If you 
disagree with this determination, you may request a redetermination within 120 days of the date 
of this letter (unless you show us otherwise, receipt is presumed to be five (5) days from the date 
of this letter).  You have the right to raise the same issues under this procedure as you would 
have in the context of non-sampling claims determinations of Part B services billed to the Fiscal 
Intermediary, and overpayment recovery.  (See 42 CFR 405.801, et seq. and 42 CFR 405.701, et 
seq.) You may ask for a redetermination of the denials for which you are determined to be liable 
under 1879 of the Act or for which the beneficiary is determined to be liable under 1879 of the 
Act, but declined, in writing, to exercise his/her appeal rights, and determinations for which you 
are found to be not without fault under 1870 of the Act.  You may also challenge the validity of 
the sample selection and the validity of the statistical projection of the sample results to the 
universe.  (Refer to the appeals procedure in your Provider Manual Section __________ for 
further details.) 
 
IF YOU HAVE FILED A BANKRUPTCY PETITION 
 
If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare 
financial obligations will be resolved in accordance with the applicable bankruptcy process.  
Accordingly, we request that you immediately notify us about this bankruptcy so that we may 
coordinate with both the Centers for Medicare & Medicaid Services and the Department of 
Justice so as to assure that we handle your situation properly.  If possible, when notifying us 
about the bankruptcy, please include the name the bankruptcy is filed under and the district 
where the bankruptcy is filed. 
 
If you have any questions regarding this matter, please contact _________ at ___________. 
(Provide correspondence address.) 
 
Thank you in advance for your prompt attention to this matter. 
 
Sincerely, 
 
Enclosures 
 
7.4.1 - Exhibit: Attachment to the Part B Letter Notifying the Provider of the 
Results, and Request Repayment of Overpayments  (Rev.) 
 
The following is a list of the claims denied as a result of the review: 
A.         Beneficiary Name:  John Smith 
  1.   HI Claim Number:  000-00-0000 A 
  2.   Service Dates:  12/08/96 - 12/08/96 
  3.   Services Denied and Dates:  Magnetic Resonance Imaging (MRI) 12/08/96 
  4.   Reason for Denial:  MRIs are not considered medically reasonable and necessary for 
the diagnosis of xxxx (1879 denial). 
  5.   Why You Are Responsible:  We find that you knew or should have known that 
payment would not be made for such items or services under Part A, and you are not without 
fault in accordance with 1870 of the Social Security Act.  You knew or should have known that 
the services were not medically reasonable and necessary because you were notified in a 
Provider Bulletin.  The Bulletin dated April 1, 1996, outlined Local Medical Review Policy 
which indicated that MRIs were not covered for the diagnosis of xxxx.  Therefore, you are 
responsible for paying the overpayment amount. 
  6.   Overpayment: $900.00 
B.        Beneficiary Name: Mary Smith 
  1. HI Claim Number:  000-00-0000 B 
  2. Service Dates:  01/01/97 - 01/31/97 
  3. Services Denied and Dates:  Physical Therapy evaluation and re-evaluation on 
01/03/97 and 01/26/97 
  4. Reason for Denial:  The two Physical Therapy visits are not medically reasonable and 
necessary because the medical documentation shows that the patient was ambulatory and had no 
functional problems which would have required a physical therapy evaluation or re-evaluation 
(1879 denial). 
  5. Why You Are Responsible:  We find that you knew or should have known that 
payment would not be made for such items or services under Part A, and you are not without 
fault in accordance with 1870 of the Social Security Act.   In a letter dated 10/30/96, you were 
notified that such therapy evaluation and re-evaluation were not considered medically reasonable 
and necessary.  Therefore, you are responsible for the overpayment. 
6. Overpayment:  $200.00 
 
 
 
Exhibit 8  Victimized Provider Process Letter Templates   (Rev. 943; Issued: 02-21-20; Effective: 03-24-20; Implementation: 03-24- 20) 
 
Letter 1:  Send to the Medicare Provider/Supplier when you begin your evaluation of the 
potential identity theft.  
 
[Date] 
 
Dear [Name of Medicare Provider/Supplier]:   
 
VPP Case #  
 
This letter serves notice that CMS has received your complaint alleging that your identity has 
been stolen or compromised and that you have suffered unwarranted Medicare related financial 
liabilities as a result.    
 
The Victimized Provider Project (VPP) was established by the Centers for Medicare & Medicaid 
Services (CMS) for the purpose of assisting Medicare providers/suppliers who have been victims 
of identity theft, and who have consequently suffered liabilities in the form of unwarranted 
Medicare related financial obligations to the Federal government (e.g., overpayment 
determinations).  CMS, in coordination with its Program Integrity Contractors, conducts an 
extensive investigation of the allegation; reviews any documentation submitted by the provider 
regarding the theft (including actions taken to report the theft and to prevent additional loss); 
evaluates any associated financial liabilities or overpayments; and then makes a final decision 
regarding the case.   
 
Where evidence compellingly demonstrates that the Medicare provider/supplier is a victim of 
identity theft, the Medicare provider/supplier shall be released from financial liability 
specifically associated with specific overpayment(s) associated with the fraudulent claims at 
issue.  Where insufficient evidence exists to release a Medicare provider/supplier from financial 
liability, the Medicare provider/supplier shall still have the right to appeal any overpayments and 
any related claim determinations through Medicares established appeals process, and/or to 
provide any additional evidence, as appropriate, to seek a new VPP decision.   
 
CMS is in the process of investigating your complaint and reviewing the materials you have 
submitted.  CMS or its Program Integrity Contractors may be contacting you for further 
information, and you may be asked to sign an attestation, under penalty of perjury, regarding the 
circumstances of the identity theft.  CMS will strive to make a decision no later than 60 days 
from the date of receipt of your complete attestation and documentation package.  
 
[Name of UPIC] is the Program Integrity Contractor that will be gathering evidence related to 
your case.  Your Point of Contact (POC) is: 
 
[Name and Contact Information] 
 
If you have any additional information that you believe will be helpful to your case, please 
provide it to the POC.  Please note that CMS and the Program Integrity Contractors are assisted 
best in these investigations and decisions if Medicare providers/suppliers supply the most 
comprehensive evidence up-front in order to make the investigative and review process as 
efficient, effective, and informed as possible. The Program Integrity Contractor will conduct an 
investigation based on evidence received, as well as through other evidence known to it or 
otherwise obtained, and will present its findings to CMS for a final decision.  The Program 
Integrity Contractor will notify you of CMSs decision in writing.   
Please note that the potential release from financial liability for fraudulent claims submitted in 
your name is restricted solely to those claims, and that the release from financial liability shall 
not attach to claims that are not the subject of this investigation.  Further, the VPP is only for 
providers who have suffered actual financial harm as a result of identity theft; it is not for 
Medicare providers/suppliers whose identities may have been stolen, but who have incurred no 
Medicare financial liability.  If you believe that you have been a victim of identity theft, but you 
have not suffered consequent financial liability, please contact [Name of Contractor] to report the 
theft and provide as much information as possible to assist CMS to prevent further misuse. 
 
Sincerely, 
 
[Program Integrity Contractor Manager Name and Title] 
[Office/Organization]  
 
 
Letter 2:  Send to the Medicare Provider/Supplier if CMS decided that identity theft has 
likely occurred and overpayment collection should stop. 
 
[Insert Date] 
 
[Insert identifying information regarding specific overpayment(s) and affected claims] 
 
Dear [Name of Medicare Provider/Supplier]: 
 
VPP Case #  
 
As we previously informed you, the Victimized Provider Project (VPP) was established by the 
Centers for Medicare & Medicaid Services (CMS) for the purpose of assisting Medicare 
providers/suppliers who have been victims of identity theft, and who have consequently suffered 
liabilities in the form of unwarranted Medicare related financial obligations to the Federal 
government (e.g., overpayment determinations). This letter serves notice that CMS has 
completed its VPP investigation of your identity theft complaint and has decided that sufficient 
information exists to confirm identity theft and to relieve you of certain debt(s).  CMS has made 
a decision that you should not be held liable for the following overpayment(s) (describe dollar 
amount(s) and timeframe(s) of claims at issue).  Therefore, pursuant to Chapter 4 of the 
Medicare Financial Management Manual (IOM Publication 100-06), the Medicare 
Administrative Contractor (MAC) shall stop its collection efforts upon receipt of CMS 
notification.  Specifically, the MAC shall: 
 
1.  Update its systems, as appropriate, to reflect rescission of the overpayment; 
2.  Refund any recoupment made against you on the specified overpayment(s) and/or 
affected claims; 
3.  Stop the recoupment against you on the specified overpayment(s) and/or affected 
claims;  
4.  Discontinue sending demand letters to you on the specified overpayment(s) and/or 
affected claims; 
5.  Not refer any specified overpayment(s) and/or affected claims to the Department of 
Treasury for collection; 
6.  Recall all specified overpayment(s) and/or affected claims on the debt/s referred to the 
Department of Treasury.   
Please note that the foregoing is solely limited to the specified overpayment(s) and/or affected 
claims, and shall not apply to claims or overpayments that were not the subject of this case.  If 
you have any questions, please contact: 
 
[Point of Contact at UPIC and Contact Information]  
 
 
Sincerely, 
 
[Program Integrity Contractor Manager Name and Title] 
[Office/Organization]  
 
 
Letter 3:  Send to the Medicare Provider/Supplier if CMS informs you that it is unable to 
determine that identity theft has occurred and overpayment notice with appeal rights has 
already been issued. 
 
[Insert Date] 
 
[Identifying Information Regarding Overpayment(s) and Affected Claims] 
 
Dear [Name of Medicare Provider/Suppliers]: 
 
VPP Case # ________________________ 
 
As we previously informed you, the Victimized Provider Project (VPP) was established by the 
Centers for Medicare & Medicaid Services (CMS) for the purpose of assisting Medicare 
providers/suppliers who have been victims of identity theft, and who have consequently suffered 
liabilities in the form of unwarranted Medicare related financial obligations to the Federal 
government (e.g., overpayment determinations). This letter serves notice that CMS has 
completed its VPP investigation of your identity theft allegation with regard to the identified 
overpayment(s) and/or affected claims, and has decided that insufficient information exists at 
this time to support a finding of identity theft.   
 
Please be advised that this decision does not affect your appeal rights.  You were previously 
afforded appeal rights in your notice of overpayment, and we refer you to your previously issued 
overpayment determination notice for guidance on such appeal rights. 
 
Sincerely, 
 
[Program Integrity Contractor Manager Name and Title] 
[Office/Organization]  
 
Exhibit 9 - Projection Methodologies and Instructions for Reviews of Home Health 
Agencies for Claims Not Paid Under PPS 
(Rev.) 
 
Preamble  These methodologies shall be used in conjunction with the instructions found in 
Chapter 3, 3.10  Use of Statistical Sampling for Overpayment Estimation. 
  A.   Reimbursement Methods for Home Health Agencies (HHAs) 
Based on the findings from the statistical sampling for overpayment estimation, the Fiscal 
Intermediary (FI)/Regional Home Health Intermediary (RHHI) will project by discipline to the 
universe from which the sample was drawn to derive an overpayment amount.  They determine 
the sample universe by discipline (e.g., skilled nursing, physical therapy) for a specified time 
frame within a single cost reporting period.  They determine the reimbursement method for the 
service(s) reviewed as shown below to ascertain the appropriate projection methodology to be 
used.  
The HHAs are reimbursed as follows: 
  Discipline: Patient Services--Reimbursed By Cost Per Visit  
  Skilled Nursing;  
  Physical Therapy;  
  Occupational Therapy;  
  Speech Pathology;  
  Medical Social Services; and  
  Home Health Aide Service  
  Other Patient Services - Reimbursed By Lower of Costs or Charges  
  Cost of Medical Supplies;  
  Cost of Drugs  
Note that the reimbursement methodology for HHA's was changed by the BBA for cost report 
periods beginning on or after October 1, 1997. 
B.  Procedures for Disciplines 1 through 6, which are reimbursed by cost per visit: 
The following procedures apply to disciplines 1 through 6, which are reimbursed by cost per 
visit: 
  The sample may be chosen from a frame including claims with a particular or many 
disciplines;  
  For each discipline, MR determines the total number of visits and number of visits denied 
by re-adjudication;  
  The lower limit of a one-sided 90% confidence interval for the proportion of services to 
be denied is to be used in computing overpayments. If use of the one-side 90% 
confidence interval results in a zero or negative, or presents other problems, see the 
guidance in Chapter 3,  3.10.1.5  Consultation with a Statistical Expert; Chapter 3, 
3.10.1.6  Use of Other Sampling Methodologies; and Chapter 3, 3.10.5.1  The Point 
Estimate on alternative scientific methodologies that may be employed for estimating the 
overpayment and consultation with a statistical expert.    Multiply the proportion obtained above by the total number of Medicare visits in the 
frame. This will determine the projected total number of visits to be denied for the period 
and the adjusted Medicare visits;  
  If the adjustment occurs prior to the submission of the cost report, the projected denied 
visits will be multiplied by the provider's interim payment rate per visit to determine the 
overpayment amount by discipline subject to collection.  The FI/RHHI will proceed to 
collect the overpayment amount based on discussion with the provider regarding 
repayment options;  
  Upon submission of the cost report, total visits on the cost report will not change.  The 
cost per visit computation will remain the same.  Only the Medicare visits and the total 
cost of Medicare services will be reduced.  The charges that are applicable to these 
adjusted costs must also be determined.  Both of these adjusted totals are needed to settle 
the cost report.  For cost report periods beginning prior to 10/1/97, HHA cost reports are 
settled on the lesser of reasonable cost or customary charges.  Under the BBA, for cost 
report periods beginning on or after 10/1/97, the methodology for settling HHA cost 
reports has changed.  Medical Review staff must complete worksheets 1-7  and notify 
Audit and Reimbursement staff of all necessary adjustments so that the amount can 
properly be reflected in the cost report.   
Worksheets 1 through 7 may be accessed by clicking on the links below: 
Worksheet 1: Home Health Agency (HHA) Calculation of Medical Review Audit Adjustment, 
Form HHA/Audit-1 
Worksheet 2: Home Health Agency (HHA) Calculation of Charges Applicable to 
Adjusted/Denied Visits, Form HHA/Audit-2 
Worksheet 3: Home Health Agency (HHA) Medical Review Sampling Results, Form HHA/MR-
1, page 1 
Worksheet 4: Home Health Agency (HHA)Medical Review Sampling Results, Form HHA/MR-
1, page 2 
Worksheet 5: Home Health Agency (HHA)Medical Review Sampling Results, Form HHA/MR-
1, page 3 
Worksheet 6: Home Health Agency (HHA) Summary of Results Medical Review Sampling - 
Form HHA/MR-2 
Worksheet 7: Home Health Agency (HHA) Summary of Results of Medical Review - Form 
HHA/MR-3 
C.  Procedures for Other Patient Services 
The following procedures apply to other patient services: 
  The sample may be chosen from a frame including claims with a particular or many 
revenue centers;     For each revenue center, MR determines the total charges and the charges in the sample 
denied by re-adjudication;  
  Determine the ratio of denied Medicare charges to the total Medicare charges in the 
sample and the 90 percent confidence interval for the ratio.  The estimated proportion is a 
ratio estimate and therefore requires a formula for the standard error appropriate to ratio 
estimation;  
  The lower bound of the confidence interval for the proportion of charges to be denied is 
to be used in computing overpayments.  If the lower bound is zero or negative, there is no 
overpayment;  
  Multiply the proportion obtained above by the total Medicare charges in the period under 
review and compute the projected total denied charges;  
  Apply the ratio of cost to charges to the revised charges to determine approved costs;  
  This results in the amount of denied dollars and constitutes the amount subject to 
adjustment;  
  If the adjustment occurs prior to the submission of the cost report, the FI/RHHI will 
proceed to collect the overpayment amount based on discussion with the provider 
regarding repayment options; and  
  Upon submission of the cost report, as in the case for disciplines 1 through 6, medical 
review staff must complete worksheets 1 - 7 identified in 5.3.7B above, and provide 
audit and reimbursement staff with the information necessary to adjust the cost report and 
to initiate overpayment collection procedures.  
D.  Coordination Between Medical Review and Audit and Reimbursement Staff 
To preserve the integrity of Provider Statistical and Reimbursement Report (PS&R) data relative 
to paid claims and shared systems data relative to denied claims, and to ensure proper settlement 
of costs on provider cost reports, certain principles must be used when projecting overpayments 
to a universe with HHAs.  Communication between the FI/RHHI's medical review and audit and 
reimbursement units is essential.  These two units must be careful to follow the procedures listed 
below: 
  The same data must be used when the projection is made as was used when the sample 
was selected;  
  Projections on denied HHA services must be made for each discipline and revenue 
center, as instructed above;  
  When notifying the provider of the review results for cost reimbursed services, MR must 
explain that the stated overpayment amount represents an interim payment 
adjustment.  Indicate that subsequent adjustments may be made at cost report settlement 
to reflect final settled costs;  
  Information from the completed Worksheets 1 - 7 identified in 5.3.7B above, must be 
routed to the FI/RHHI's audit and reimbursement staff.  In addition to the actual and 
projected overpayment amounts, the information must provide the number of denied 
services (actual denied services plus projected denied services) for each discipline and the 
amounts of denied charges (actual denied amounts plus projected denied amounts) for 
supplies and drugs; and     Upon completion of the review, furnish the audit and reimbursement staff with the 
information listed in PIM Chapter 3 5.3.1.  
The audit and reimbursement staff will: 
  Determine the actual overpayment to be recovered for cost based services based on the 
denied services, units and charges, and the provider's allowed costs;  
  Use the information on denied services to ensure accurate settlement of the cost report 
and/or any adjustments to interim rates that may be necessary as a result of MR findings. 
Audit adjustments will be made to PS&R statistics on the cost report to decrease 
Medicare visits, increase other visits (total visits remain unchanged) and to adjust 
Medicare charges, as necessary; and  
  In the event that a cost report has been settled, determine the impact and the actions to be 
taken.  In most cases, it is expected that cost reports will not have been settled or even 
filed.  
 
Exhibit 10 - Projection Methodologies and Instructions for Reviews of Skilled 
Nursing Facilities (SNFs) for Claims not Paid Under PPS 
(Rev.) 
 
Preamble  These methodologies shall be used in conjunction with the instructions found in 
Chapter 3, 3.10  Use of Statistical Sampling for Overpayment Estimation. 
 
A.  Projecting From a Sample to a Universe on SNF Claims 
Based on the findings from the statistical sampling for overpayment estimation, the FI will 
project by ancillary cost center, to the universe from which the sample was drawn to derive an 
overpayment amount. They determine the sample universe by ancillary service for a specified 
time frame within a single cost reporting period. 
Ancillary Service Cost Centers reimbursed by Lower of Costs or Charges are: 
  Radiology;  
  Laboratory;  
  IV Therapy;  
  Oxygen Therapy;  
  Physical Therapy;  
  Occupational Therapy;  
  Speech Pathology;  
  Electrocardiology;  
  Medical Supplies;  
  Drugs Charged; and     Other  
NOTE:   Effective July 1, 1998, SNF services will be reimbursed in accordance with the 
provisions in the BBA.  
The following procedures should be used to determine the sample universe by ancillary service 
for a specified time frame within a single cost reporting period: 
  The sample may be chosen from a frame including claims with a particular or many 
revenue centers;  
  For each revenue center, determine the total charges and the charges in the sample denied 
by re-adjudication;  
  The lower limit of a one-sided 90% confidence interval for the proportion of charges to 
be denied is to be used in computing overpayments. If use of the one-side 90% 
confidence interval results in a zero or negative, or presents other problems, see the 
guidance in Chapter 3, Sections 3.10.1.5, 3.10.1.6, and 3.10.5.1 on alternative scientific 
methodologies that may be employed for estimating the overpayment and consultation 
with a statistical expert;  
  Multiply the proportion obtained above by the total Medicare charges in the period under 
review and compute the projected total denied charges;  
  Apply the ratio of cost to charges to the revised charges to determine approved costs;  
  This results in the amount of denied dollars and constitutes the amount subject to 
adjustment;  
  If adjustment occurs prior to the submission of the cost report, the FI shall proceed to 
collect the overpayment amount based on discussion with the provider regarding 
repayment options; and  
  Upon submission of the cost report, Medical Review staff will complete Worksheets 8 - 
17, and provide the Audit and Reimbursement staff with the information necessary to 
adjust the cost report and to initiate overpayment collection procedures.  
Worksheets 8 through 17 may be viewed by double clicking on the name (link) below: 
Worksheet 8: Skilled Nursing Facility (SNF) Calculation of Medical Review Audit Adjustment - 
Form SNF/MR-1, page 1 
Worksheet 9: Skilled Nursing Facility (SNF) Medical Review Sampling Results - Form 
SNF/MR-1, page 1 
Worksheet 10: Skilled Nursing Facility (SNF) Medical Review Sampling Results - Form 
SNF/MR-1, page 2 
Worksheet 11: Skilled Nursing Facility (SNF) Medical Review Sampling Results - Form 
SNF/MR-1, page 3 
Worksheet 12: Skilled Nursing Facility (SNF) Medical Review Sampling Results - Form 
SNF/MR-1, page 4  Worksheet 13: Skilled Nursing Facility (SNF) Medical Review Sampling Results - Form 
SNF/MR-1, page 5 
Worksheet 14: Skilled Nursing Facility (SNF) Medical Review Sampling Results - Form 
SNF/MR-1, page 6 
Worksheet 15: Skilled Nursing Facility (SNF) Medical Review Sampling Results - Form 
SNF/MR-1, page 7 
Worksheet 16: Skilled Nursing Facility (SNF) Summary of Results of Medical Review Sampling 
- Form SNF/MR-2 
Worksheet 17: Skilled Nursing Facility (SNF) Summary of Results of Medical Review - Form 
SNF/MR-3 
B.  Coordination Between Medical Review and Audit and Reimbursement Staff 
To preserve the integrity of the PS&R data relative to paid claims and shared systems data 
relative to denied claims, and to ensure proper settlement of costs on provider cost reports, 
certain principles must be used when projecting overpayments to a universe with 
SNFs.  Communication between the FI/RHHI's medical review and audit and reimbursement 
units is essential.  These two units must be careful to follow the procedures listed below: 
  The same data must be used when the projection is made as was used when the sample 
was selected; 
  Projections for denied SNF services must be made by each individual ancillary cost 
center, as instructed above;  
  Denied charges must be segregated between Part A and Part B as the SNF Medicare cost 
report is set up to apportion costs and make separate settlements for Part A and Part B;  
  When notifying the provider of the review results, MR must explain that the stated 
overpayment amount represents an interim payment adjustment.  They indicate that 
subsequent adjustments may be made at cost settlement to reflect final settled costs;  
  Information from the completed worksheets 8 - 17 (PIM chapter 3, 5.3.8 above), must 
be routed to the FI's audit and reimbursement staff.  In addition to the actual and 
projected overpayment amounts, the information must provide the amount of denied 
charges (actual denied plus projected denied amounts); and  
  Upon completion of the review, MR furnishes the audit and reimbursement staff with the 
information listed in PIM chapter 3 5.3D.  
The audit and reimbursement staff will: 
  Determine the actual overpayment to be recovered based on the denied charges; and  
  In the event that a cost report has been settled, they determine the impact and the actions 
to be taken.  It is expected that, in most cases, cost reports will not have been settled or 
even filed.   Exhibit 11 - Projection Methodologies and Instructions for Reviews of 
Comprehensive Outpatient Rehabilitation Facilities (CORFS) for Claims Not Paid 
Under PPS  
(Rev.) 
 
Preamble  These methodologies shall be used in conjunction with the instructions found in 
Chapter 3, 3.10  Use of Statistical Sampling for Overpayment Estimation. 
 
A.  Projecting From a Sample to a Universe on CORF Claims 
Based on the findings from the statistical sampling for overpayment estimation, the FI will 
project by ancillary cost center to the universe from which the sample was drawn to derive an 
overpayment amount.  They determine the sample universe by ancillary service for a specified 
time frame within a single cost reporting period.  When making this determination, the following 
should be used: 
  Ancillary Service Cost Centers that are reimbursed by reasonable costs are:  
  Skilled Nursing Care;  
  Physical Therapy;  
  Speech Pathology;  
  Occupational Therapy;  
  Respiratory Therapy;  
  Medical Social Services;  
  Psychological Services;  
  Prosthetic and Orthotic Devices;  
  Drugs and Biologicals;  
  Supplies Charged to Patients;  
  DME - Sold; and  
  DME - Rented.  
The following procedures should be used to determine the sample universe by ancillary service 
for a specified time frame within a single cost reporting period: 
  The sample may be chosen from a frame including claims with a particular or many 
revenue centers;  
  For each revenue center, MR determines the total charges and the charges in the sample 
denied by re-adjudication;  
  The lower limit of a one-sided 90% confidence interval for the proportion of charges to 
be denied is to be used in computing overpayments. If use of the one-side 90% 
confidence interval results in a zero or negative, or presents other problems, see the 
guidance in Chapter 3, Sections 3.10.1.5, 3.10.1.6, and 3.10.5.1 on alternative scientific  methodologies that may be employed for estimating the overpayment and consultation 
with a statistical expert;  
  Multiply the proportion obtained above by the total Medicare charges in the period under 
review and compute the projected total denied charges;  
  Apply the ratio of cost to charges to the revised charges to determine approved costs;  
  This results in the amount of denied dollars and constitutes the amount subject to 
adjustment;  
  If adjustment occurs prior to the submission of the costs report, the FI shall proceed to 
collect the overpayment amount based on discussion with the provider regarding 
repayment options; and  
  Upon submission of the cost report, medical review staff will complete Worksheets 24 - 
30, then provide audit and reimbursement staff with the information necessary to adjust 
the cost report and to initiate overpayment collection procedures.  
Worksheets 24 through 30 may be viewed by double clicking on the name (link) below: 
Worksheet 24: Comprehensive Outpatient Rehabilitation Facility (CORF) Calculation of 
Medical Review Audit Adjustment - Form CORF/Audit-1 
Worksheet 25: Comprehensive Outpatient Rehabilitation Facility (CORF) Medical Review 
Sampling Results - Form CORF/MR-1, page 1 
Worksheet 26: Comprehensive Outpatient Rehabilitation Facility (CORF) Medical Review 
Sampling Results - Form CORF/MR-1, page 2 
Worksheet 27: Comprehensive Outpatient Rehabilitation Facility (CORF) Medical Review 
Sampling Results - Form CORF/MR-1, page 3 
Worksheet 28: Comprehensive Outpatient Rehabilitation Facility (CORF) Medical Review 
Sampling Results - Form CORF/MR-1, page 4 
Worksheet 29: Comprehensive Outpatient Rehabilitation Facility (CORF) Summary of Results 
of Medical Review Sampling - Form CORF/MR-2 
Worksheet 30: Comprehensive Outpatient Rehabilitation Facility (CORF) Summary of Results 
of Medical Review - Form CORF/MR-3 
B.  Coordination Between Medical Review and Audit and Reimbursement Staff 
To preserve the integrity of the PS&R data relative to paid claims and shared systems data 
relative to denied claims, and to ensure proper settlement of costs on provider cost reports, 
certain principles must be used when projecting overpayments to a universe with 
CORFs.  Communication between the FI/RHHI's medical review and audit and reimbursement 
units is essential.  These two units must be careful to follow the procedures listed below: 
  The same data must be used when the projection is made as was used when the sample 
was selected;     Projections for denied CORF services must be made by each individual ancillary cost 
center, as instructed above;  
  When notifying the provider of the review results, MR must explain that the stated 
overpayment amount represents an interim payment adjustment.  Indicate that subsequent 
adjustments may be made at cost settlement to reflect final settled costs;  
  Information from the completed worksheets 24 - 30 in PIM chapter 3, 5.3.9A, must be 
routed to the FI's audit and reimbursement staff.  In addition to the actual and projected 
overpayment amounts, the information must provide the amount of denied charges 
(actual denied plus projected denied amounts); and  
  Upon completion of the review, furnish the Audit and Reimbursement staff with the 
information listed in PIM chapter 3 5.3D.  
The audit and reimbursement staff will: 
  Determine the actual cost report overpayment to be recovered based on the denied 
charges; and  
  In the event that a cost report has been settled, they determine the impact and the actions 
to be taken.  In most cases, it is expected that cost reports will not have been settled or 
even filed.  
 
Exhibit 12 - Projection Methodologies and Instructions for Reviews of Community 
Mental Health Centers (CMHCs) for Claims not Paid Under PPS - (Rev.) 
 
Preamble  These methodologies shall be used in conjunction with the instructions found in 
Chapter 3, 3.10  Use of Statistical Sampling for Overpayment Estimation. 
A.  Projecting From a Sample to a Universe on CMHC Claims 
Based on the findings from the statistical sampling for overpayment estimation, the FI will 
project by ancillary cost center to the universe from which the sample was drawn to derive an 
overpayment amount.  Determine the sample universe by ancillary service for a specified time 
frame within a single cost reporting period.  
When making this determination, the following should be used: 
Ancillary service cost centers that are reimbursed by lower of costs or charges are: 
  Drugs and Biologicals  
  Occupational Therapy  
  Individualized Activity Therapy  
  Psychiatric/Psychological Services  
  Individual Therapy  
  Group Therapy  
  Family Counseling     Diagnostic Services  
  Patient Training and Education  
The following procedures should be used to determine the sample universe by ancillary service 
for a specified time frame within a single cost reporting period. 
  The sample may be chosen from a frame including claims with a particular or many 
revenue centers;  
  For each revenue center, determine the total charges and the charges in the sample denied 
by re-adjudication;  
  The lower limit of a one-sided 90% confidence interval for the proportion of services to 
be denied is to be used in computing overpayments. If use of the one-side 90% 
confidence interval results in a zero or negative, or presents other problems, see the 
guidance in [Chapter 3, Sections 14.1.5, 14.1.6, and 14.5.1] on alternative scientific 
methodologies that may be employed for estimating the overpayment and consultation 
with a statistical expert;  
  Multiply the proportion obtained above by the total Medicare charges in the period under 
review and compute the projected total denied charges;  
  Apply the ratio of cost to charges to the revised charges to determine approved costs;  
  This results in the amount of denied dollars and constitutes the amount subject to 
adjustment;  
  If adjustment occurs prior to the submission of the cost report, the FI shall proceed to 
collect the overpayment amount based on discussion with the provider regarding 
repayment options; and  
  Upon submission of the cost report, medical review staff will complete worksheets 18 - 
23, then provide audit and reimbursement staff with the information necessary to adjust 
the cost report and to initiate overpayment collection procedures.  
Worksheets 18 through 23 may be viewed by double clicking on the name (link) below: 
Worksheet 18: Community Mental Health Clinic (CMHC) Calculation of Medical Review Audit 
Adjustment - Form CMHC/Audit-1 
Worksheet 19: Community Mental Health Clinic (CMHC) Medical Review Sampling Results - 
Form CMHC/Audit-1, page 1 
Worksheet 20: Community Mental Health Clinic (CMHC) Medical Review Sampling Results - 
Form CMHC/Audit-1, page 2 
Worksheet 21: Community Mental Health Clinic (CMHC) Medical Review Sampling Results - 
Form CMHC/Audit-1, page 3 
Worksheet 22: Community Mental Health Clinic (CMHC) Summary of Results of Medical 
Review Sampling - Form CMHC/MR-2 
Worksheet 23: Community Mental Health Clinic (CMHC) Summary of Results of Medical 
Review - Form CMHC/MR-3  B.  Coordination Between Medical Review and Audit and Reimbursement Staff 
To preserve the integrity of the PS&R data relative to paid claims and shared systems data 
relative to denied claims, and to ensure proper settlement of costs on provider cost reports, 
certain principles must be used when projecting overpayments to a universe with 
CMHCs.  Communication between the FI/RHHI's medical review and audit and reimbursement 
units is essential.  These two units must be careful to follow the procedures listed below: 
  The same data must be used when the projection is made as was used when the  sample 
was selected;  
  Projections for denied CMHC services must be made by each individual ancillary cost 
center, as instructed above;  
  When notifying the provider of the review results, MR must explain that the stated 
overpayment amount represents an interim payment adjustment.  They indicate that 
subsequent adjustments may be made at cost settlement to reflect final settled costs; and  
  Information from the completed worksheets 18 - 23 in PIM chapter 3,  5.3.10A must be 
routed to the FI's audit and reimbursement staff.  In addition to the actual and projected 
overpayment amounts, the information must provide the amount of denied charges 
(actual denied plus projected denied amounts).  
The audit and reimbursement staff will: 
  Determine the actual overpayment to be recovered based on the denied charges; and  
  In the event that a cost report has been settled, they determine the impact and the actions 
to be taken.  In most cases, it is expected that cost reports will not have been settled or 
even filed.  
 
Exhibit 13 - Postpayment CMR Summary Report Format Example 
(Rev. 3, 11-22-00) 
 
Identification Section 
Provider  Provider Number 
Address  ID No. (SSN or EIN) 
If Group, Number of Providers Involved 
See attached for names and individual earnings 
Specialty  Sub-specialty 
Repeat providers (years) 
Payment and Utilization Section 
Payments: Year  Assigned $  Unassigned $ 
Total Number of Beneficiaries: 
Average Number of Services Per Beneficiary: 
Average Payment Per Beneficiary  Provider on Prepayment Review: 
For Which Services/procedures: 
For What Period: 
 
Carrier Review Conducted Section 
Reason Provider Selected for Comprehensive Medical Review: 
Areas on which Comprehensive Medical Review efforts were concentrated: 
See attached for all procedures for which provider exceeded established 
norms. 
Material Reviewed 
Claims Sampling Method: 
Number of Beneficiaries:  Number of Months per Beneficiary: 
Computer Printouts (Specify): 
Medical Records (Specify): 
Other Records (Specify): 
Did Medical Staff Review Cases?  If so, what percent? 
Contacts Made  Number of Cases Reviewed  Reason 
Provider 
SNF 
Hospital 
Beneficiary 
 
 
Documentation of 1879 of the Act Determinations Section 
List the evidence and rationale indicating that the provider knew or should have known that the 
services were not medically reasonable and necessary.  
Documentation of 1870 of the Act Determinations Section 
List the evidence and rationale indicating that the provider was "at fault" in causing the 
overpayment and that the provider is liable for the overpayment (i.e., recovery of overpayment 
will not be waived).  
Exhibit 13.1 - Excluded Providers - (Rev. 3, 11-22-00) 
 
A.  Notice to Beneficiaries 
To ensure that the notice to the beneficiary indicates the proper reason for denial of payment, 
contractors include the following language in the notice:  "We have received a claim for services furnished by _____________ on 
______________.  Effective _______________,  _________________was excluded from 
receiving payment for items and services furnished to Medicare beneficiaries.  This notice is to 
advise that no payment will be made for any items or services furnished by 
______________________________ if rendered more than 20 days from the date of this notice." 
B.  Notice to Others 
The Medicare Patient and Program Protection Act of 1987 provides that payment is denied for 
any items or services ordered or prescribed by a provider excluded under 1128 or 1156 of the 
Act.  It also provides that payment cannot be denied until the supplier of the items and services 
has been notified of the exclusion. 
If claims are submitted by a laboratory or a DME company for any items or services ordered or 
prescribed by a provider excluded under 1128 or 1156 of the Act, contractors: 
  Pay the first claim submitted by the supplier and immediately give notice of the 
exclusion; and  
  Do not pay the supplier for items or services ordered or prescribed by an excluded 
provider if such items or services were ordered or prescribed more than 20 days after the 
date of notice to the supplier, or after the effective date of the exclusion, whichever is 
later.  
To ensure that the notice to the supplier indicates the proper reason for denial of payment, 
contractors include the following language in the notice: 
"We have received a claim for services ordered or prescribed by __________________________ 
on _______________.  Effective ____________________, _____________________was 
excluded from receiving payment for items or services ordered or prescribed for Medicare 
beneficiaries.  This notice is to advise that no payment will be made for any items or services 
ordered or prescribed by ________________ if ordered or prescribed more than 20 days from the 
date of this notice." 
Exhibit 14 - Contractor Denials 1862(a)(1) of the Act - (Rev. 3, 11-22-00) 
 
The determinations which follow a 1862(a)(1) denial may require a decision if the beneficiary 
or provider knew or could have known that a service would not be covered by Medicare because 
it would be considered medically unnecessary.  The provider is liable if it is determined the 
provider knew, or could reasonably have been expected to know, that the items or services 
provided were not covered under Medicare. The beneficiary is liable if it is determined the 
beneficiary knew, or could reasonably have been expected to know (e.g. utilization review notice 
from a SNF) that the items or services provided were not covered under Medicare. However, the 
Medicare program accepts liability (i.e., makes payment to a provider even though a non-covered 
service is involved) if neither the beneficiary nor the provider knew, or could reasonably be 
expected to have known, that the services were not covered.  Waiver of liability exists when both 
the beneficiary and the provider did not and could not reasonably have been expected to know 
that payment would not be made for services. 
To find that a beneficiary knew or should have known that a service would not be covered, 
written notice from the provider is required or evidence that the beneficiary had received a prior 
denial for the same or similar services.  To find that a provider had knowledge that a service  would not be covered, actual or constructive notice is acceptable (e.g., carrier bulletin with final 
LMRP and effective date).  Sufficient notice includes: 
  Previous denials for the same service;  
  Publication by the contractor in a newsletter or other communication to the provider 
community that a service is considered not reasonable and necessary or constitutes custodial 
care;  
  Knowledge based on experience; and  
  Local standards of practice.  
 
14.1 - Section 1879 of the Act Determination- Limitation of Liability - (Rev. 3, 
11-22-00) 
 
Section 1879 provides relief for a beneficiary who acted in good faith in accepting services 
found to be not reasonable and necessary for the diagnosis or treatment of illness or injury or to 
improve the functioning of a malformed body member, or to constitute custodial care.  The 
provision also applies to denials of home health services beginning July 1, 1987 and ending 
September 30, 1989, where the beneficiary is not homebound or does not or did not need skilled 
nursing care on an intermittent basis. The provision applies to all carrier determinations on all 
assigned claims when claims are denied (prepay or postpay) under 1862(a)(1) of the 
Act.  Contractors must make an individualized determination for each claim that is denied as not 
reasonable and necessary. 
A 1879 determination regarding knowledge is part of the framework for determining whether 
an actual or potential overpayment exists.  If a contractor determines that program payment was 
proper because neither the beneficiary nor the provider knew or should have known that the 
service was not reasonable and necessary, no overpayment exists.  However, if the contractor 
determines that either the beneficiary or the provider knew or should have known that a service 
was not medically reasonable and necessary, an overpayment exists.  Contractors must consider 
waiver of recovery of the overpayment under 1870 of the Act. 
A.  Documentation of 1879 of the Act Determination 
The contractor must document the basis for the determination (i.e., rationale), including 
appropriate references to contractor newsletters, prior denials, sponsored meetings attended by 
the provider, etc., where applicable.  Any correspondence going to the beneficiary/provider (i.e., 
demand letters) should include all 1879 determinations as to knowledge of noncoverage, both 
favorable and unfavorable. Document the 1879 determination in the CMR summary report. 
B.  Section 1879 of the Act Determinations and Overpayments 
An overpayment would be $0 (zero) for postpayment denials for assigned claims and claims 
submitted to an intermediary from a participating provider because a determination was made 
that neither the beneficiary nor the provider knew or should have known the services were not 
covered. Program payment was appropriate.  However, if the beneficiary is found to be liable 
under 1879 of the Act, an overpayment to the beneficiary exists and the contractor must make 
an 1870 determination.  14.2 - Section 1870 of the Act Determination - Waiver of Recovery of an 
Overpayment 
(Rev. 3, 11-22-00) 
 
Once the contractor has concluded that an overpayment exists (i.e., postpayment review, 
including 1879 of the Act waiver determinations is complete), it makes a 1870 determination 
regarding waiver of recovery of the overpayment from the provider. Carriers make this 
determination for all claims where the provider took assignment. Section 1870, waiver of 
recovery, is not applicable for the provider on non-assigned postpayment 1862(a)(1) of the Act 
denied claims because the overpayment is a beneficiary overpayment.  The provider may have a 
refund obligation to the beneficiary, but the provider did not receive an overpayment from the 
Medicare program. 
Section 1870 is not limited to claims under 1862(a)(1) (A) of the Act denied for not being 
reasonable and necessary. Section 1870 is the framework for determining whether overpayment 
recovery is waived.  For providers taking assignment, waiving recovery of an overpayment is 
appropriate where the provider was without fault with respect to causing the overpayment. 
Where recovery from the provider is waived, the overpayment becomes an overpayment to the 
beneficiary.  However, if the provider was "at fault" in causing the overpayment, recovery of the 
overpayment from the provider must proceed. Section 1870 waiver of recovery determinations 
also must be made where the provider mistakenly receives direct payment on an unassigned 
claim and this is the basis for the overpayment. 
If 1879 of the Act is applicable, the 1879 determination is made first since an overpayment 
does not exist if payment can be made under 1879 because there was a lack of knowledge by 
both the beneficiary and the provider. 
A.  Documentation of 1870 of the Act Determination 
The contractor must document the basis for the determination (i.e., rationale), including 
appropriate references to contractor newsletters, prior denials, sponsored meetings attended by 
the provider, etc., where applicable.  Any correspondence going to the beneficiary or provider 
(i.e., demand letters) should include all 1870 refund determinations.  Also, document the 1870 
determination in the CMR summary report. 
B.  Section 1870 of the Act Determinations and Overpayments 
Where waiver of recovery from the provider is appropriate under 1870, the contractor must 
show an overpayment amount, but also indicate that recovery is being waived. 
C.  Section 1870 of the Act Determinations and Extrapolations 
If recovery of an overpayment from the provider for one or more claims is waived under 
1870  (i.e., the provider was without fault), the amount waived must be included when 
extrapolating in order to get a true projected overpayment as to exactly how much recovery is 
being waived.  Contractors should subtract the projected waived amount from the projected 
overpayment amount to get the amount the provider must repay. 
14.3 - Section 1842(l) of the Act Determination - Refunds to Beneficiary 
(Rev. 3, 11-22-00)   
For 1862(a)(1) of the Act denials on non-assigned claims involving physician or supplier 
services, carriers must make a determination under 1842(l) regarding whether the physician or 
supplier must refund any payment collected from the beneficiary. This should be done for initial 
determinations (prepay) and for postpayment denials. 
Carriers make a 1842(l) physician or supplier refund determination if the reviewer concludes 
that the services were not reasonable and necessary. For physician or supplier claims where 
assignment was not taken, a 1842(l) refund determination must be made. Carriers must make a 
determination for each claim that is denied as not reasonable and necessary. 
A physician or supplier cannot be considered overpaid if payment was not made to the physician 
for the claim. A physician or supplier who takes assignment on a claim-by-claim basis may be 
audited and the sample may include some non-assigned claims. Consideration of a refund on the 
non-assigned claims denied based on 1862(a)(1)(A) of the Act is appropriate, but a finding that 
a refund is appropriate does not create a Medicare overpayment. 
A.  Documentation of 1842(l) of the Act Determination 
The carrier must document the basis for the determination (i.e., rationale), including appropriate 
references to contractor newsletters, prior denials, sponsored meetings attended by the provider, 
etc., where applicable. Any correspondence going to the beneficiary or physician, or supplier 
(i.e., demand letters) should include all 1842(l) refund determinations. Document 1842(l) 
determinations in the CMR summary report. 
B.  Section 1842(l) of the Act Determination With Respect to Overpayments 
A physician refund obligation under 1842(l) is not a determination of a program overpayment. 
If the refund obligation arises in connection with a postpayment denial, any overpayment would 
be a beneficiary overpayment. 
Exhibit 14.4 - Effect of Sections 1879 and 1870 of the Social Security Act 
During Postpayment Reviews  
(Rev. 17, 12-12-01) 
 
The Medicare law contains two provisions that affect the determination and the recovery of 
overpayments. One is 1879 of the Act, which deals with limitation on liability for services 
determined to be noncovered because they are, for example, custodial or are not reasonable and 
necessary under Medicare law, or, for home health services, the patient is not confined to home 
or the skilled nursing services are not intermittent. If the denial involves items or services to 
which the provisions of 1879 (limitation on liability) apply, MR makes a determination in 
accordance with instructions in MIM 3431, MCM 7300and CMS Ruling 95-1. 
The other law affecting the determination and the recovery of overpayments is 1870 of the Act, 
which provides a framework within which liability for overpayments is determined and recovery 
of overpayments is pursued. If the denial of a claim involves items or services to which the 
provisions of 1879 (limitation on liability) do not apply, or if an overpayment results from a 
1879 determination that either the beneficiary or the provider is liable, contractors make a 
determination as to whether the provider was without fault for the overpayment under the 
provisions of 1870 in accordance with MIM 3431and MCM 7300.  Exhibit 15 - Consent Settlement Documents - (Rev. 3, 11-22-00) 
(Rev. 96, Issued: 01-14-05, Effective: 02-14-05, Implementation: 02-14-05) 
 
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 requires 
several letters to be sent to providers or suppliers regarding consent settlement.  Contractors shall 
send to the provider or supplier a request for additional information letter, a consent settlement 
offer letter, and a no action letter if an overpayment was not found or if an overpayment was 
found, a letter requesting the moneys owed. 
 
A.  First Letter in the Consent Settlement Process: Opportunity to Submit Additional 
Information Before Consent Settlement Offer Notification 
 
Before a consent settlement is offered, contractors must communicate in writing to the provider 
or supplier that they have the opportunity to submit additional information.  This document shall: 
 
  Explain there may be an overpayment due to an initial evaluation of the records; 
  Highlight the nature of the problems in the providers or suppliers billing and practice 
patterns identified as a result of the preliminary audit; 
  Give steps the provider or supplier can take to address the problems; and 
  Identify the forty-five (45) day time frame to furnish this additional information. 
 
List the following information in the heading of the letter: 
  Date of notice; 
  Name of provider; 
  Address; and 
  City, state, and zip code. 
Italics within parentheses indicate insertions and must not be inserted in correspondence going to 
providers.   
Under Section 1842 of the Social Security Act, carriers under contract to the Centers for 
Medicare & Medicaid Services are authorized to "make audits of the records of providers of 
services as may be necessary to assure that proper payments are made under this part."  We are 
responsible for conducting audits of providers to ensure that Medicare Part B claims have been 
billed and paid appropriately. 
Based on our preliminary evaluation of your medical records on__________,_ (Fill in date) we 
have found an indication of a potential overpayment.  The purpose of this letter is to describe the 
nature of the problems identified in our evaluation, the steps that you should take to address 
these problems, and give you the time frame to furnish additional information concerning the 
medical records for the claims being reviewed. 
 
During our initial evaluation, we have ascertained the following issues, 
(List the problems found.)   
  To resolve these issues and to determine that there is an overpayment, the following are the steps 
you may take: 
(List action that can be taken to resolve the problems.)  
 
You have forty-five (45) days from the receipt of this letter, ____to submit any additional 
information concerning the medical records for the claims being reviewed in this evaluation.   
Send this information to _________.  If you have any questions, please contact me at______. 
 
B.  Second Letter in the Consent Settlement Process: Consent Settlement Offer 
Consent settlement documents must closely conform to the content of the model language 
provided below.  The consent settlement documents shall explain: 
 
  The responsibility of CMS in conducting audits of providers or suppliers to ensure 
that Medicare Part B claims have been billed and paid appropriately; 
  The date of the initial request for records prior to conducting the audit; 
  The steps involved in the audit process; 
  The problems in the providers or suppliers billing and practice patterns identified as 
a result of the audit;  
  To notify the provider or supplier of the potential overpayment calculated as a result 
of the audit; and  
  Two options available to the provider or supplier. 
 
NOTE:  The Consent Settlement Documents shall include information regarding statistical 
sampling for overpayment estimation.  Refer to 3.10 of the Program Integrity Manual (PIM) for 
instructions for the use of statistical sampling for overpayment estimation. 
List the following information in the heading of the letter: 
  Date of notice; 
  Name of provider; 
  Address; and 
  City, state, and zip code. 
Italics within parentheses indicate insertions and must not be inserted in correspondence going to 
providers.   
Under Section 1842(a)(1)(C) of the Social Security Act, carriers under contract to the Centers for 
Medicare & Medicaid Services are authorized to "make audits of the records of providers of 
services as may be necessary to assure that proper payments are made under this part."  We are 
responsible for conducting audits of providers to ensure that Medicare Part B claims have been 
billed and paid appropriately. 
On __________________, [Fill-in date of initial request for records prior to conducting audit.] 
you received a notification letter stating that you had the opportunity to submit additional 
information to us after our preliminary evaluation of your records indicated a potential  overpayment.  On __________________, [Fill-in date of initial request for records prior to 
conducting audit.] you also received our request for records to conduct an audit of your 
practice.  The purpose of this letter and attachments is to describe the steps involved in the audit 
process, to highlight problems in your billing and practice patterns identified as a result of our 
audit, to notify you of the potential overpayment calculated as a result of our audit, and to outline 
two options available to you. 
Our normal full-scale audit process entails the review of records using statistical sampling for 
overpayment estimation.  However, in the interest of economy and expediency for both you and 
the Medicare program, as a first step, we elected to perform a limited audit.  We reviewed claims 
and medical records for services rendered to     beneficiaries over a period of time, 
from____________to____________.  While__________beneficiaries were randomly selected 
for our sample from a larger universe of beneficiaries for whom you provided services, it is not 
done based on our instructions for conducting statistical sampling for overpayment estimation.   
You were chosen for an audit because______________________ [Fill-in the reason for the 
audit.  The reason may be exceeding peer norms or a call from a beneficiary.  For example, if the 
provider exceeded peer norms the contractor might want to use the following language:  "You 
were chosen for an audit because our records indicate you exceeded the average utilization rates 
of your peers by______% for the same time period.  Your specialty is listed 
as__________________.  The peer group consisted of__________          who billed for the same 
procedure(s)."]  We selected the ____________ beneficiaries by identifying the procedure codes 
where your billing exceeded the norm for your peers.  Included in the universe are only those 
beneficiaries for whom you rendered and billed at least one of these procedure codes that was 
paid by Medicare during the review period.  From this universe of beneficiaries, a computer is 
used to randomly select the beneficiaries to be included in the sample.  All claims for the 
procedure codes at issue that were rendered to the sampled beneficiaries and paid within 
the                time period were audited.  [This sentence may be modified depending upon whether 
the audit used the date of service or the date of payment for selecting claims.  As it is stated, all 
claims would have to actually been paid within the time period. Whichever method is used, you 
must be consistent.] The list of sampled beneficiaries, dates of service, and procedure codes is 
contained in the attachment to this letter. 
The beneficiaries included in our audit resulted in claims being paid by Medicare 
between____________________.  [See note in preceding paragraph.   Similar rewording may be 
required here.]  These claims and their corresponding medical records were audited, resulting in 
a potential overpayment of $__________including an actual overpayment of $___________for 
the________ beneficiaries. Item 3 under "Audit Results" explains how we calculated the 
potential overpayment. Please review the attached documents containing the audit results and 
options along with an explanation of the Extended Repayment Plan. 
We must have your response to this letter within sixty (60) days from the date of this 
letter,____________ If we do not receive a response from you by_______________ , statistical 
sampling for overpayment estimation will be chosen for you by default (see attached discussion 
of audit results). Be advised that by signing this letter your legal options may be affected. Please 
also be advised that repayment of the overpayment specified herein in no way affects or limits 
the rights of the Federal Government or any of its agencies or agents to pursue any appropriate 
criminal, civil, or administrative remedies arising from or relating to these or any other claims. 
You may wish to have legal counsel review this letter before signing it.  If you have any 
questions, please contact me   at______________________________. 
Sincerely, 
Attachments 
C.  Consent Settlement Attachment 1 Audit Results 
IDENTIFYING INFORMATION 
 List the following information in the heading of the attachment: 
  Date;  
  Provider Name;  
  Provider Address; and  
  Provider Number.  
 
SCOPE OF AUDIT 
This audit covers services that were paid by Medicare 
from____________________to____________________. [Modify this sentence depending upon 
whether the audit used the date of service or the date of payment for selecting claims.  As it is 
currently stated, all claims would have to have  been acutally paid within the time 
period.  Whichever method is used, you must be consistent.] 
The audit revealed the following problems in your billing and practice patterns: 
ISSUES/DETERMINATIONS 
A physician reviewer, specializing in __________________________ [You are required to have 
a medical specialist involved in the review of the sample claims that are not based on application 
of clearly articulated existing MR policy.  Fill-in the specialty here.] was consulted during the 
audit process.  The following claims and submitted records of determinations were used in the 
review. 
[This area lists the problem areas noted above, such as exceeding peer norms and medical 
necessity/documentation concerns.  Additionally, each of the sampled beneficiaries, dates of 
services, procedure codes, and the Medical Director's determination on each denied service is 
noted here.  Attach newsletters discussing medical policy and documentation requirements for 
the problem areas found during the audit.] 
[This is also the area where you explain the 1879 and 1870 determinations, perhaps using, in 
part, the following language: 
For 1879: "Based on available information, we believe you knew or should have known that..." 
For1870: "We have made the determination that you were not "without fault" in causing the 
overpayment.  Therefore, we are not waiving your obligation to repay.  We cannot find you 
without fault because..."  Rationale for the 1879 and/or 1870 findings might include all or part of the following 
language:] 
"The management of a medical or supplier practice that includes a large number of Medicare 
beneficiaries must understand the conditions governing which services will be covered and 
payable under Part B of the Medicare Program. Pertinent information was available from the law 
and regulations [provide a cite, if possible], from [cite name/issue number of carrier newsletter], 
from a meeting you attended on date, and from your peers in the medical community ." 
Carriers need to make specific findings for 1879 and 1870. The rationale for finding provider 
knowledge or fault with regard to a particular claim may not be the same as for another claim. 
This may be so even for multiple denials for a particular code since MN is a unique and 
individualized determination. These individual findings are especially important if #167;1879 
and/or 1870 determinations are partially favorable. In such cases, specify which of the sample 
claims are affected, why, and how much this reduces the actual and total potential overpayment 
amounts (see 1879) or reduces the amount of the actual and total potential overpayments which 
must be refunded (see 1870). 
Because 1879 and 1870 determinations are difficult concepts, it is important to explain to 
physicians exactly why they are being held responsible under these provisions. Your explanation 
must go beyond conclusory statements and/or findings.] 
CALCULATIONS 
A copy of our calculation worksheet is enclosed for your information.  To calculate the potential 
projected overpayment amount for each denied procedure code, the following formula was used: 
[In this section, insert a complete explanation of the methodology used to calculate the 
overpayment and the projected overpayment for each denied procedure code. The explanation 
must include the formula used when the audited services were down coded rather than denied 
and when only one example of a procedure code was audited.] 
Procedure Co Denied  Denied  Down-coded  Down- Potential 
de  Services         #Sam Services    #Univer Services   #Samp coded  Overpayme
ple  se  le  Services  nt 
#Univers
e 
[This table lists procedure codes, the number of services in the sample and in the universe that 
were denied or down-coded, and the resulting potential overpayment amount.] 
The actual overpayment amount is  $_______________.  The sum of all potential projected 
procedure code overpayments, including the actual overpayment amount, is $_______________. 
OPTIONS 
You must now select one of the two options explained below. Our normal audit process entails 
the routine use of Option One.  However, we are now making another option available to you as 
a consent settlement.  If you fail to notify us of your selected option, Option One (Election to Proceed to Statistical 
Sampling for Overpayment Estimation) will automatically be selected for you by default. Be 
aware that when statistical sampling for overpayment estimation is selected for audit, records for 
all of the services at issue must be available for review. 
Please send in your response to the options listed below within sixty (60) days from the date of 
this letter,_______________ . 
Regardless of the option selected, beneficiaries may not be billed for any of the overpayment 
amount. 
Option One Election to Proceed to Statistical Sampling for Overpayment Estimation 
If we do not hear from you within sixty (60) days from the date of this letter, _______________, 
we will proceed with Option One by default. [This is the second step in the audit process if you 
have been offered a consent settlement on a potential overpayment but do not accept the offer.] 
This step utilizes statistical sampling for overpayment estimation for the same universe or time 
period.  Your right to appeal to a Hearing Officer, an administrative law judge or to the court 
remains if you should choose this option. Also, any rights available to you under 1870 and/or 
1879 of the Social Security Act remain. 
Be aware that this option, either by your selection or by default, means that you are required to 
submit medical documentation for all of the services at issue in the statistical sampling for 
overpayment estimation [(just as you would have had to do if we had not first offered you the 
opportunity for a consent settlement on a potential overpayment).] You should also be aware that 
this option, whether selected by you or by default, withdraws the option of a consent settlement, 
as described in Option Two. 
If you elect (or accept by default) Option One, it is important that you understand the following 
information concerning our actions and your responsibilities with regard to the actual 
overpayments found for the claims involved in the limited audit: 
The potential projected overpayment referred to in this correspondence is based on a sample of 
_______________ beneficiaries.  We audited claims and medical documentation for 
the_______________ beneficiaries in the sample to arrive at an actual overpayment for these 
claims.  The actual overpayment amount was then projected to the universe of procedure codes 
to develop the potential projected overpayment.  (See above for the actual overpayment amount 
and the potential projected overpayment amount.) 
Option Two involves repayment of the potential projected overpayment, which includes the 
actual overpayment amount. Choosing Option One does not eliminate your obligation to repay 
the actual overpayment. Recoupment of the actual overpayment identified for the claims in the 
limited audit will be pursued individually, but their recovery will be credited against any 
projected overpayment for the universe to which the claims belong.  Your obligation to repay the 
overpayment for these claims will begin on the date of the official notification of 
overpayment.  You will be notified of your appeal rights on these claims at this same time. 
Option Two Acceptance of Consent Settlement Offer  You agree to repay the potential projected overpayment, after providing additional medical 
documentation relevant to the____ beneficiaries involved in our sample which was in existence 
at the time the services were rendered.  
Review of this information will result in one of three decisions: 
  All services in contention could be determined to be appropriate and allowed as 
originally processed, and the question of any potential overpayment would be eliminated; 
or  
  A portion of the services in question could be determined to be appropriate and allowed 
as originally processed, and the amount of the potential overpayment would decrease 
accordingly; or  
  The audit results could remain the same and the potential projected overpayment would 
remain at $_______________. 
  
You may request a meeting to explain the additional documentation or to provide other 
information relevant to the redetermination. 
If you select Option Two, you agree to refund the revised potential overpayment amount, if any, 
which will not exceed the dollar amount calculated in Item 3 of this attachment and printed 
above.  
The revised potential overpayment amount will not exceed the capped amount. 
By selecting this option, regarding repayment, you agree that there was a problem in your billing 
as identified by the carrier, you intend to correct this problem in future billings, and you 
understand how we reached the potential overpayment, i.e., you understand the sampling 
methodology used and the methodology to project the potential overpayment.  Because you 
agree that there was a problem and agree to make changes in your practice to resolve this 
problem, you waive your right to appeal the sampled individual overpayments, the potential 
overpayment resulting from the projection and the sampling procedures.  The appeal rights you 
are waiving include a hearing before a Hearing Officer, Administrative Law Judge, or in the 
Courts. You also waive any rights you have under 1870 and/or 1879 of the Social Security Act. 
(Please see Items 6 and 7 in this attachment for a discussion of these rights.) 
Election of Option Two means that, in the absence of potential fraud, we will not audit your 
claims for any procedure codes projected in our audit during the audit time frame again. In the 
event of fraud and/or if you fail to correct the identified problems, we reserve the right to audit 
prior years' claims and claims for any procedure codes for the time period considered in this 
audit. 
ASSESSMENT OF INTEREST 
We wish to make you aware, should you elect Option Two, that interest will be assessed on any 
balance outstanding thirty (30) days from the date of the letter notifying you of a final potential 
overpayment, if any.   Should you choose Option One, interest will be assessed on any balance 
outstanding thirty (30) days from the date of the letter notifying you of a final overpayment 
determination.  We must assess interest as provided in 42 CFR 405.376.  Interest will accrue on 
the unpaid balance for each thirty (30) day period (or portion thereof) that repayment is 
delayed.  The current interest rate is _______________ %.  LIMITATION OF LIABILITY 
Section 1879 of the Social Security Act (42 USC 1395pp, 42 CFR 411.406) permits Medicare 
payment to be made to providers on assigned claims for certain services otherwise not covered 
because they were not reasonable or necessary for the diagnosis or treatment of illness or injury 
or to improve the functioning of a malformed body member, or were custodial services if neither 
the beneficiary nor the provider knew, or could reasonably be expected to know, that the services 
were not medically necessary or were for custodial care. Services affected are those disallowed 
as not reasonable or necessary for the diagnosis or treatment of illness or injury, or to improve 
the functioning of a malformed body member and those disallowed as custodial services. 
WAIVER OF OBLIGATION TO REPAY UNDER 1870 OF THE SOCIAL SECURITY ACT 
Section 1870 of the Social Security Act (42 USC 1395gg, 42 CFR 405.704(b)(14)) permits 
you to request waiver of an overpayment on the grounds that you were "without fault" with 
respect to causing the overpayment. This determination is made after 1879 is considered.  If it is 
determined that you or the beneficiary knew or should have known that the service was not 
medically necessary and reasonable or constituted custodial care as described under the 
provisions of 1879, we address 1870 and determine whether you were "without fault" with 
respect to causing the overpayment. 
GENERAL 
We wish to ensure that you are aware of regulations and provisions of the law relating to 
continuation of the problems discussed herein.  They include exclusion from the Medicare 
Program in accordance with 1128(b) of the Social Security Act (42 USC 1320a-7), civil 
monetary penalties or other actions in accordance with 1128A of the Social Security Act (42 
USC 1320a-7a), and/or, if appropriate, withholding payment under 42 CFR 405.370. 
Your decision regarding this matter must be in writing and received by this office within sixty 
(60) days from the date of this letter. If your decision is not received by the above-mentioned 
date, Option One, Election to Proceed to statistical sampling for overpayment estimation, will be 
selected for you by default. 
We have enclosed two copies each of the two option forms for your convenience. Select one of 
the options, complete and sign both forms corresponding to that option, and send them to my 
personal attention at the address shown below. 
The provider must personally sign the forms. A signature stamp, or the signature of a staff 
member or attorney is not acceptable. After receipt of the two identical option forms with 
authorized signatures, we will sign both forms and return one to you. 
Name: 
Title: 
Address: 
Telephone number:  D.  Consent Settlement Attachment 2: Option One - Election To Proceed To Statistical Sampling 
For Overpament Estimation 
Option One - Election to Proceed to Statistical Sampling for Overpayment Estimation 
I,______________________________: 
  have read the results of the audit findings in the letter dated _____________.  
  elect to proceed to your full-scale audit process, involving use of statistical sampling for 
overpayment estimation for the same universe of procedure codes and time period as the 
limited audit, as explained in the letter.  I understand the full-scale audit process is the 
normal audit process, and that the limited audit was offered to me only in the interest of 
economy and expediency. Upon selection of Option One, I understand that the offer of a 
consent settlement as stated in Option Two is withdrawn.  
  understand that I and/or my office staff will be required to submit medical documentation 
for all services at issue in the statistical sampling for overpayment estimation, upon 
request by the carrier.  
  understand that all applicable appeals rights, including any right to a hearing officer 
hearing, an administrative law judge hearing, or court review are available to me. I also 
retain any rights available under 1879 and/or 1870 of the Social Security Act, as 
appropriate.  
  understand that the claims from the above-referenced limited audit will not be selected 
for inclusion in the statistical sampling for overpayment estimation; the statistical 
sampling for overpayment estimation will be a new and independent audit.  
  understand that the overpayment identified for claims in the limited audit will be pursued 
on an individual basis, and that this overpayment will be subtracted from any 
overpayment resulting from the statistical sampling for overpayment estimation; that I 
will be provided with appeal rights regarding the overpayment amount on the claims in 
the limited audit at a later date; and that any interest on the overpayment amount on the 
claims in the limited audit will be calculated from the date of this later notice with appeal 
rights.  
  understand that the rights of the Federal Government or any of its agencies or agents to 
pursue any appropriate criminal, civil, or administrative remedies arising from or relating 
to these or any other claims are in no way affected or limited by selection of this option. 
Provider signature: _________________________ 
Date signed: ______________________________ 
Printed or typed name: ______________________ 
Title of signatory: __________________________ 
Carrier Representative Signature: ______________ 
Date signed: _____________________________  Printed or typed name: _______________________ 
Title of signatory: ___________________________ 
Please submit both copies of the selected option form, with original signatures, in the enclosed 
envelope. Upon completion, a file copy will be returned to you. 
E.  Consent Settlement Attachment 3 Option Two - Acceptance of Consent Settlement Offer  
I,_____________________________: 
  have read the results of the audit findings in the letter dated_______________.  
  understand the issues the carrier presented and the calculation of the projected potential 
overpayment and agree to settle the issue of a potential projected overpayment by 
refunding a redetermined amount of up to $_________________to Medicare. This 
amount was derived by reviewing a sample of my claims and determining that a potential 
overpayment did exist within the universe of my claims.  
  have enclosed additional documentation for you to review for the purpose of 
redetermining the potential overpayment. I understand that I may request a meeting to 
explain the additional documentation or to provide other information relevant to the 
redetermination. I understand the redetermined potential overpayment, if any, will not 
exceed the amount shown above.  
  understand that if the redetermined settlement amount is not refunded to Medicare within 
thirty (30) days from the date of the redetermined potential overpayment notice, the 
unpaid balance is subject to offset. I may apply for an extended repayment plan and, if 
approved, may make payments over an approved period of time.  
  understand that interest on the amount accrues from the date of the final potential 
overpayment determination, but that this interest will be waived if repayment is made 
within thirty (30) days from the date of the final potential overpayment determination.  
  understand that claims paid to me from ______________ to_______________will not be 
audited in the future. [Reword this statement to reflect services dates if service dates were 
used in the audit to select claims instead of dates of payment.] I further understand that in 
the event of fraud or if I fail to correct the identified problems, the carrier reserves the 
right to audit prior years' claims and claims for any procedure codes for the time period 
considered in this audit.  
  understand that the rights of the Federal Government or any of its agencies or agents to 
pursue any appropriate criminal, civil, or administrative remedies arising from or relating 
to these or any other claims are in no way affected or limited by selection of this option. 
I,___________________________, agree by settling this: 
  that my right to appeal, which includes a Medicare Part B hearing officer hearing, 
administrative law judge hearing, or any court appeals regarding this matter, is waived. I 
also understand any rights available to me under 1879 and/or 1870 of the Social 
Security Act are waived.  
I,____________________________, do/do not (circle one) wish to request a meeting at this time 
to discuss the additional documentation I have submitted.  Provider signature:_______________________ 
Date signed:____________________________ 
Printed or typed name:____________________ 
Title of signatory:________________________ 
Carrier Representative Signature:____________ 
Date signed:_________ 
Printed or typed name:____________________ 
Title of signatory:_________________________ 
Please submit both copies of the selected option form, with original signatures, in the enclosed 
envelope. Upon completion, a file copy will be returned to you. 
F.  Consent Settlement Attachment 4: Extended Repayment Plan (ERP) 
It has been determined by an audit that there is a potential overpayment amount due to 
Medicare.  It is expected that you will remit the entire amount in one payment within thirty (30) 
days of the date of the final potential overpayment determination if you select Consent 
Agreement Option Two (Acceptance of Consent Settlement Offer), or, if you select Option One 
(Election to Proceed to Statistical Sampling for Overpayment Estimation), the date of the final 
overpayment determination. However, if you are unable to repay the amount within that time, we 
are authorized to consider repayment in installments based on validated financial 
hardship.  [Installments are based on the amount of the overpayment as stated in Financial 
Management, Chapter 4, 20, 30.] Installments can range from 2-6 months based on the amount 
of overpayment.  Be aware that if repayment is not made within thirty (30) days, interest will be 
due.  If you select Consent Agreement Option Two, interest accrues from the date of the final 
potential overpayment determination, or if you elect Option One, interest accrues from the date 
of the final overpayment determination (See 42 CFR 405.378.). Interest will be waived if 
repayment is made within thirty (30) days of the applicable date cited above for the option 
chosen.  The current rate of interest is _______ percent.  If you wish to claim financial hardship, 
contact _______________________ to obtain the financial statement of debtor form (CMS-379). 
This form must be completed and returned with your request for approval of an installment 
schedule. If compliance with the above is not acceptable to you, it is suggested that you seek a 
private or commercial loan to satisfy the obligation. 
If repayment of the amount due, in a lump sum or on an approved installment plan, is not 
forthcoming, the Centers for Medicare & Medicaid Services may, at its option; forward the case 
to the Department of Justice or the Internal Revenue Service (IRS) for enforced collection. 
G (1). Third Letter in the Consent Settlement Process:  No Action if an Overpayment Was Not 
Established 
 
List the following information in the heading of the letter:    Date of notice; 
  Name of provider; 
  Address; and 
  City, state, and zip code. 
Italics within parentheses indicate insertions and must not be inserted in correspondence going to 
providers.   
 
You have already received correspondence regarding a potential consent settlement.  Thank you 
for your cooperation in this process.  Based on our evaluation of your medical records 
on__________,_ (Fill in date) we have not found an indication of an overpayment.  No 
additional action on your part, is deemed necessary. 
 
If you have any questions, please contact me at______. 
 
Sincerely, 
 
G (2).  Third Letter in the Consent Settlement Process:  Request for Money Owed if 
Overpayment was Established 
 
List the following information in the heading of the letter: 
  Date of notice; 
  Name of provider; 
  Address; and 
  City, state, and zip code. 
Italics within parentheses indicate insertions and must not be inserted in correspondence going to 
providers.   
 
You have already received correspondence regarding a potential consent settlement.  Thank you 
for your cooperation in this process.  Based on our evaluation of your medical records 
on__________,_ (Fill in date) we have found an indication of an overpayment and the option of 
a (state if provider elected the statistical sampling for overpayment estimation or accepted the 
consent settlement offer) was selected. You owe ___(state the amount of money owed).   
 
If you have any questions, please contact me at______________________________. 
Sincerely, 
  Exhibit 16 - Model Payment Suspension Letters 
(Rev. 11218; Issued: 01-27-2022; Effective: 02-28-2022; Implementation: 02-28-2022) 
 
A. Payment Suspension Initial Notice Based on Fraud (No Prior Notice Given) 
 
Date  
 
Name of Addressee (if known)  
Name of Medicare Provider/Supplier  
Address 
City, State Zip 
 
Re:   Notice of Suspension of Medicare Payments Provider/Supplier  
Medicare ID Number(s): 
Provider/Supplier NPI: 
PSP Number: 
 
Dear {Medicare Provider/Suppliers Name}: 
 
The purpose of this letter is to notify you of our determination to suspend your Medicare 
payments {INSERT THE FOLLOWING IF THIS IS A NATIONAL PAYMENT 
SUSPENSION: in all jurisdictions} pursuant to 42 C.F.R.  405.371(a)(2). The suspension of 
your Medicare payments took effect on {ENTER DATE}. Prior notice of this suspension was 
not provided, because giving prior notice would place additional Medicare funds at risk and 
hinder the Centers for Medicare & Medicaid Services (CMS) ability to recover any determined 
overpayment. See 42 C.F.R.  405.372(a)(3) and (4). 
 
The CMS through its Central Office made the decision to suspend your Medicare payments. See 
42 C.F.R.  405.372(a)(4)(iii). This suspension is based on credible allegations of fraud. See 42 
C.F.R.  405.371(a)(2). CMS regulations define credible allegations of fraud as an allegation 
from any source including, but not limited to, fraud hotline complaints, claims data mining, 
patterns identified through audits, civil false claims cases, and law enforcement investigations. 
See 42 C.F.R.  405.370(a). Allegations are considered credible when they have indicia of 
reliability. See 42 C.F.R.  405.370. This suspension may last until resolution of the investigation 
as defined under 42 C.F.R.  405.370 and may be extended under certain circumstances. See 42 
C.F.R.  405.372(d)(3).   
 
Specifically, the suspension of your Medicare payments is based on, but not limited to, 
information that you misrepresented services billed to the Medicare program. More particularly, 
{Continue with further supportive information and specific examples (no less than five). Only 
use claim numbers, date of service, amount paid and basis for selected claim when referencing 
the specific claim examples. Do Not use beneficiary names or HIC#s in the notice.}. 
 
The following list of sample claims provide evidence of our findings and serve as a basis for the 
determination to suspend your Medicare payments: 
 
Claim Control Number  Date(s) of Service  $$ Amount Paid     Basis for Selected Claim 
 
This list is not exhaustive or complete in any sense, as the investigation into this matter is 
continuing. The information is provided by way of example in order to furnish you with adequate 
notice of the basis for this payment suspension.   
Pursuant to 42 C.F.R.  405.372(b)(2), you have the right to submit a rebuttal statement in 
writing to us indicating why you believe the suspension should be removed. If you opt to do so, 
we request that you submit this rebuttal statement to us within 15 days of receipt of this notice, 
and you may include with this statement any evidence you believe supports your reasons why the 
suspension should be removed. If you choose to submit a rebuttal statement, your rebuttal 
statement and any pertinent evidence should be sent to: 
 
{YOUR NAME}, Program Integrity Analyst 
 {ADDRESS} 
 
If you submit a rebuttal statement, we will review that statement (and any supporting 
documentation) along with other materials associated with the case. Based on a careful review of 
the information you submit and all other relevant information known to us, we will determine 
whether the suspension should be removed, or should remain in effect within 15 days of receipt 
of the complete rebuttal package, consistent with 42 C.F.R.  405.375. However, the suspension 
of your Medicare funds will continue while your rebuttal package is being reviewed. See 42 
C.F.R.  405.375(a).  Thereafter, we will notify you in writing of our determination to continue 
or remove the suspension and provide specific findings on the conditions upon which the 
suspension may be continued or removed, as well as an explanatory statement of the 
determination. See 42 C.F.R.  405.375(b)(2). This determination is not an initial determination 
and is not appealable. See 42 C.F.R.  405.375(c). 
 
If the suspension is continued, we will review additional evidence during the suspension period 
to determine whether claims are payable and/or whether an overpayment exists and, if so, the 
amount of the overpayment. See 42 C.F.R.  405.372(c). We may need to contact you with 
specific requests for further information. You will be informed of developments and will be 
promptly notified of any overpayment determination(s). Claims will continue to be processed 
during the suspension period, and you will be notified about bill/claim determinations, including 
appeal rights regarding any bills/claims that are denied. The payment suspension also applies to 
claims in process. 
 
In the event that an overpayment is determined and it is determined that a recoupment of 
payments under 42 C.F.R.  405.371(a)(3) should be put into effect, you will receive a separate 
written notice of the intention to recoup and the reasons. Please be advised that CMS may charge 
interest on the amount of the overpayment, consistent with 42 C.F.R.  405.378.  In the written 
notice alerting you to the overpayment, you will be given an opportunity for rebuttal in 
accordance with 42 C.F.R.  405.374 from {MAC name}, CMS Medicare Administrative 
Contractor (MAC). When the payment suspension has been removed, any money withheld as a 
result of the payment suspension shall be applied first to reduce or eliminate any determined 
overpayment by CMS including any interest assessed under 42 C.F.R.  405.378, and then to 
reduce any other obligation to CMS or to the U.S. Department of Health and Human Services in 
accordance with 42 C.F.R.  405.372(e).  In the absence of a legal requirement that the excess be 
paid to another entity, the excess will be released to you. 
 
{Insert the following paragraph if prepayment review is being initiated} Finally, {Name of UPIC 
or MAC}, a CMS {Unified Program Integrity Contractor (UPIC) or MAC}, has initiated a 
process to review your Medicare claims and supporting documentation prior to payment. The 
purpose of implementing this prepayment process is to ensure that all payments made by the 
Medicare program are appropriate and consistent with Medicare rules, regulations and policy. 
The prepayment process is often applied to safeguard Medicare from unnecessary expenditures 
and to ensure that Medicare payments are made for items and services which are reasonable and  necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. See 42 U.S.C.  1395y(a)(1)(A). Notification is hereby given that you 
are expected to comply with the prepayment process for claims for all dates and services. 
 
Should you have any questions regarding the status of the suspension, please direct your inquiry 
to [shared mailbox].  Any request to remove the suspension must be submitted through the 
rebuttal process described above. 
 
Sincerely, 
 
Name 
 
 
B. Payment Suspension Initial Notice Based on Fraud (Prior Notice Given) 
 
Date 
 
Name of Addressee (if known)  
Name of Medicare Provider/Supplier  
Address 
City, State Zip 
 
Re:   Notice of Suspension of Medicare Payments  
Provider/Supplier Medicare ID Number(s):  
Provider/Supplier NPI: 
PSP Number: 
 
Dear {Medicare Provider/Suppliers Name}: 
 
The purpose of this letter is to notify you of our determination to suspend your Medicare 
payments {INSERT THE FOLLOWING IF THIS IS A NATIONAL PAYMENT 
SUSPENSION: in all jurisdictions} pursuant to 42 C.F.R.  405.371(a)(2). The suspension of 
your Medicare payments will take effect on {ENTER DATE}. 
 
The Centers for Medicare & Medicaid Services (CMS) through its Central Office made the 
decision to suspend your Medicare payments. See 42 C.F.R.  405.372(a)(4)(iii). This suspension 
is based on credible allegations of fraud. See 42 C.F.R.  405.371(a)(2). CMS regulations define 
credible allegations of fraud as an allegation from any source including, but not limited to, fraud 
hotline complaints, claims data mining, patterns identified through audits, civil false claims 
cases, and law enforcement investigations. Allegations are considered credible when they have 
indicia of reliability. See 42 C.F.R.  405.370. This suspension may last until resolution of the 
investigation as defined under 42 C.F.R.  405.370 and may be extended under certain 
circumstances. See 42 C.F.R.  405.372(d)(3).   
 
Specifically, the suspension of your Medicare payments is based on, but not limited to, 
information that you misrepresented services billed to the Medicare program. More particularly, 
{Continue with further supportive information and specific examples (no less than five). Only 
use claim numbers, date of service, amount paid and basis for selected claim when referencing 
the specific claim examples. Do Not use beneficiary names or HIC#s in the notice.}. 
 
The following list of sample claims provide evidence of our findings and serve as a basis for the 
determination to suspend your Medicare payments:   
Claim Control Number      Date(s) of Service  $$ Amount Paid     Basis for Selected Claim 
 
This list is not exhaustive or complete in any sense, as the investigation into this matter is 
continuing. The information is provided by way of example in order to furnish you with adequate 
notice of the basis for this payment suspension. 
 
Pursuant to 42 C.F.R.  405.372(b)(2) and 405.374, you have the right to submit a rebuttal 
statement in writing to us within the next 15 days of receipt of this notice indicating why you 
believe the suspension should not be implemented or should be removed. If you opt to do so, you 
may include with this statement any evidence you believe is pertinent to your reasons why the 
suspension should not be implemented or should be removed. If you choose to submit a rebuttal 
statement, your rebuttal statement and supporting evidence should be sent to: 
 
{YOUR NAME}, Program Integrity Analyst 
{ADDRESS} 
 
If you submit a rebuttal statement, we will review that statement (and any supporting 
documentation) along with other materials associated with the case. Based on a careful review of 
the information you submit and all other relevant information known to us, we will determine 
whether the suspension should be implemented, removed, or should remain in effect within 15 
days of receipt of the complete rebuttal package, consistent with 42 C.F.R.  405.375. 
Thereafter, we will notify you in writing of our determination to implement, continue, or remove 
the suspension and provide specific findings on the conditions upon which the suspension may 
be implemented, continued, or removed, as well as an explanatory statement of the 
determination. See 42 C.F.R.  405.375(b)(2). However, if by the end of this period no rebuttal 
has been received, the payment suspension will go into effect automatically. This determination 
is not an initial determination and is not appealable. See 42 C.F.R.  405.375(c). 
 
If the suspension is implemented or continued, we will review additional evidence during the 
suspension period to determine whether claims are payable and/or whether an overpayment 
exists and, if so, the amount of the overpayment. See 42 C.F.R.  405.372(c). We may need to 
contact you with specific requests for further information. You will be informed of developments 
and will be promptly notified of any overpayment determination. Claims will continue to be 
processed during the suspension period, and you will be notified about bill/claim determinations, 
including appeal rights regarding any bills/claims that are denied. The payment suspension 
applies to claims in process. 
 
In the event that an overpayment is determined and it is determined that a recoupment of 
payments under 42 C.F.R.  405.371(a)(3) should be put into effect, you will receive a separate 
written notice of the intention to recoup and the reasons.  Please be advised that CMS may 
charge interest on the amount of the overpayment, consistent with 42 C.F.R.  405.378. In the 
written notice alerting you to the overpayment, you will be given an opportunity for rebuttal in 
accordance with 42 C.F.R.  405.374 from {MAC name}, CMS Medicare Administrative 
Contractor (MAC). When the payment suspension has been removed, any money withheld as a 
result of the payment suspension shall be applied first to reduce or eliminate any determined 
overpayment by CMS including any interest assessed under 42 C.F.R.  405.378, and then to 
reduce any other obligation to CMS or to the U.S. Department of Health and Human Services in 
accordance with 42 C.F.R.  405.372(e). In the absence of a legal requirement that the excess be 
paid to another entity, the excess will be released to you. 
  {Insert the following paragraph if prepayment review is being initiated} Finally, {Name of UPIC 
or MAC}, a CMS {Unified Program Integrity Contractor (UPIC) or MAC}, has initiated a 
process to review your Medicare claims and supporting documentation prior to payment. The 
purpose of implementing this prepayment process is to ensure that all payments made by the 
Medicare program are appropriate and consistent with Medicare rules, regulations and policy. 
The prepayment process is often applied to safeguard Medicare from unnecessary expenditures 
and to ensure that Medicare payments are made for items and services which are reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. See 42 U.S.C.  1395y(a)(1)(A). Notification is hereby given that you 
are expected to comply with the prepayment process for claims for all dates and services. 
 
Should you have any questions regarding the status of the suspension, please direct your inquiry 
to [shared mailbox].  Any request to remove the suspension must be submitted through the 
rebuttal process described above. 
 
Sincerely, 
 
Name 
 
 
C. Payment Suspension Initial Notice Based on Reliable Information (No Prior Notice Given) 
 
Date 
 
Name of Addressee (if known)  
Name of Medicare Provider/Supplier  
Address 
City, State Zip 
 
Re:   Notice of Suspension of Medicare Payments  
Provider/Supplier Medicare ID Number(s):  
Provider/Supplier NPI: 
PSP Number: 
 
Dear {Medicare Provider/Suppliers Name}: 
 
The purpose of this letter is to notify you of our determination to suspend your Medicare 
payments {INSERT THE FOLLOWING IF THIS IS A NATIONAL PAYMENT 
SUSPENSION: in all jurisdictions} pursuant to 42 C.F.R.  405.371(a)(1). The suspension of 
your Medicare payments took effect on {ENTER DATE}. This payment suspension may last for 
up to 180 days from the effective date and may be extended under certain circumstances. See 42 
C.F.R.  405.372(d).  Prior notice of this suspension was not provided, because giving prior 
notice would place additional Medicare funds at risk and hinder the Centers for Medicare & 
Medicaid Services (CMS) ability to recover any determined overpayment. See 42 C.F.R.  
405.372(a)(3) and (4). 
 
CMS through its Central Office made the decision to suspend your Medicare payments. See 42 
C.F.R.  405.372(a)(4)(iii). The suspension of your Medicare payments is based on reliable 
information that an overpayment exists or that the payments to be made may not be correct. 
Specifically, the suspension of your Medicare payments is based on, but not limited to, 
information from claims data analysis and medical review completed by {NAME OF UPIC or 
MAC}. More particularly, {Continue with further supportive information and specific claim  examples (no less than five). Only use claim numbers, date of service, amount paid and basis for 
selected claim when referencing the claim examples. Do Not use beneficiary names or HIC#s in 
the notice.}.  
 
The following list of sample claims provide evidence of our findings and serve as a basis for the 
determination to suspend your Medicare payments: 
 
Claim Control Number  Date(s) of Service  $$ Amount Paid     Basis for Selected Claim 
 
This list is not exhaustive or complete in any sense, as the investigation into this matter is 
continuing. The information is provided by way of example in order to furnish you with adequate 
notice of the basis for this payment suspension. 
 
Pursuant to 42 C.F.R.  405.372(b)(2), you have the right to submit a rebuttal statement in 
writing to us indicating why you believe the suspension should be removed. If you opt to do so, 
we request that you submit this rebuttal statement to us within 15 days and you may include with 
this statement any evidence supporting your reasons why the suspension should be removed. If 
you choose to submit a rebuttal statement, your rebuttal statement and any pertinent evidence 
should be sent to: 
 
{YOUR NAME}, Program Integrity Analyst 
{ADDRESS} 
 
If you submit a rebuttal statement, we will review that statement (and any supporting 
documentation) along with other materials associated with the case. Based on a careful review of 
the information you submit and all other relevant information known to us, we will determine 
whether the suspension should be removed or should remain in effect within 15 days of receipt 
of the complete rebuttal package, consistent with 42 C.F.R.  405.375. However, the suspension 
of your Medicare funds will continue while your rebuttal package is being reviewed. See 42 
C.F.R.  405.375(a). Thereafter, we will notify you in writing of our determination to continue or 
remove the suspension and provide specific findings on the conditions upon which the 
suspension may be continued or removed, as well as an explanatory statement of the 
determination. See 42 C.F.R.  405.375(b)(2). This determination is not an initial determination 
and is not appealable. See 42 C.F.R.  405.375(c). 
 
If the suspension is continued, we will review additional evidence during the suspension period 
to determine whether claims are payable and/or whether an overpayment exists and, if so, the 
amount of the overpayment. See 42 C.F.R.  405.372(c). We may need to contact you with 
specific requests for further information. You will be informed of developments and will be 
promptly notified of any overpayment determination. We will continue to process claims during 
the suspension period, and you will be notified about bill/claim determinations, including appeal 
rights regarding any bills/claims that are denied. The payment suspension also applies to claims 
in process. 
 
In the event that an overpayment is determined and it is determined that a recoupment of 
payments under 42 C.F.R.  405.371(a)(3) should be put into effect, you will receive a separate 
written notice of the intention to recoup and the reasons. Please be advised that CMS may charge 
interest on the amount of the overpayment, consistent with 42 C.F.R.  405.378. In the written 
notice alerting you to the overpayment, you will be given an opportunity for rebuttal in 
accordance with 42 C.F.R.  405.374 from {MAC name}, CMS Medicare Administrative 
Contractor (MAC). When the payment suspension has been removed, any money withheld as a 
result of the payment suspension shall be applied first to reduce or eliminate any determined  overpayment by CMS including any interest assessed under 42 C.F.R.  405.378, and then to 
reduce any other obligation to CMS or to the U.S. Department of Health and Human Services in 
accordance with 42 C.F.R.  405.372(e). In the absence of a legal requirement that the excess be 
paid to another entity, the excess will be released to you. 
 
{Insert the following paragraph if prepayment review is being initiated} Finally, {Name of UPIC 
or MAC}, a CMS {Unified Program Integrity Contractor (UPIC) or MAC}, has initiated a 
process to review your Medicare claims and supporting documentation prior to payment. The 
purpose of implementing this prepayment process is to ensure that all payments made by the 
Medicare program are appropriate and consistent with Medicare rules, regulations and policy. 
The prepayment process is often applied to safeguard Medicare from unnecessary expenditures 
and to ensure that Medicare payments are made for items and services which are reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. See 42 U.S.C.  1395y(a)(1)(A).  Notification is hereby given that you 
are expected to comply with the prepayment process for claims for all dates and services. 
 
Should you have any questions regarding the status of the suspension, please direct your inquiry 
to [shared mailbox].  Any request to remove the suspension must be submitted through the 
rebuttal process described above. 
 
Sincerely, 
 
Name 
 
 
D. Payment Suspension Initial Notice Based on Reliable Information (Prior Notice Given) 
 
Date 
 
Name of Addressee (if known)  
Name of Medicare Provider/Supplier  
Address 
City, State Zip 
 
Re:   Notice of Suspension of Medicare Payments  
Provider/Supplier Medicare ID Number(s):  
Provider/Supplier NPI: 
PSP Number: 
 
Dear {Medicare Provider/Suppliers Name}: 
 
The purpose of this letter is to notify you of our determination to suspend your Medicare 
payments {INSERT THE FOLLOWING IF THIS IS A NATIONAL PAYMENT 
SUSPENSION: in all jurisdictions} pursuant to 42 C.F.R.  405.371(a)(1). The suspension of 
your Medicare payments will take effect on {ENTER DATE}. This payment suspension may 
last for up to 180 days from the effective date and may be extended under certain circumstances. 
See 42 C.F.R.  405.372(d).  
 
The Centers for Medicare & Medicaid Services (CMS) through its Central Office made the 
decision to suspend your Medicare payments. See 42 C.F.R.  405.372(a)(4)(iii).  The 
suspension of your Medicare payments is based on reliable information that an overpayment 
exists or that the payments to be made may not be correct. Specifically, the suspension of your  Medicare payments is based on, but not limited to, information from claims data analysis and 
medical review completed by {NAME OF UPIC or MAC}.  More particularly, {Continue with 
further supportive information and specific claim examples (no less than five). Only use claim 
numbers, Date of Service and amount paid when referencing the claim examples. Do Not use 
beneficiary names or HIC#s in the notice.}. 
 
The following list of sample claims provide evidence of our findings and serve as a basis for the 
determination to suspend your Medicare payments: 
 
Claim Control Number    Date(s) of Service     $$ Amount Paid     Basis for Selected Claim 
 
This list is not exhaustive or complete in any sense, as the investigation into this matter is 
continuing. The information is provided by way of example in order to furnish you with adequate 
notice of the basis for this payment suspension. 
 
Pursuant to 42 C.F.R.  405.372(b)(2) and 405.374, you have the right to submit a rebuttal 
statement in writing to us within the next 15 days indicating why you believe the suspension 
should not be implemented or should be removed. If you opt to do so, you may include with this 
statement any evidence you believe is pertinent to your reasons why the suspension should not 
be implemented or should be removed. If you choose to submit a rebuttal statement, your 
rebuttal statement and any pertinent evidence should be sent to: 
 
{YOUR NAME}, Program Integrity Analyst 
{ADDRESS} 
 
If you submit a rebuttal statement, we will review that statement (and any supporting 
documentation) along with other materials associated with the case. Based on a careful review of 
the information you submit and all other relevant information known to us, we will determine 
whether the suspension should be implemented, removed, or should remain in effect within 15 
days of receipt of the complete rebuttal package, consistent with 42 C.F.R.  405.375. 
Thereafter, we will notify you in writing of our determination to implement, continue, or remove 
the suspension and provide specific findings on the conditions upon which the suspension may 
be implemented, continued, or removed, as well as an explanatory statement of the 
determination. See 42 C.F.R.  405.375(b)(2). However, if by the end of this period no rebuttal 
has been received, the payment suspension will go into effect automatically. This determination 
is not an initial determination and is not appealable. See 42 C.F.R.  405.375(c). 
 
If the suspension is implemented or continued, we will review additional evidence during the 
suspension period to determine whether claims are payable and/or whether an overpayment 
exists and, if so, the amount of the overpayment. See 42 C.F.R.  405.372(c). We may need to 
contact you with specific requests for further information. We will inform you of developments 
and will promptly notify you of any overpayment determination(s). Claims will continue to be 
processed during the suspension period, and you will be notified about bill/claim determinations, 
including appeal rights regarding any bills/claims that are denied. The payment suspension also 
applies to claims in process. 
 
In the event that an overpayment is determined and it is determined that a recoupment of 
payments under 42 C.F.R.  405.371(a)(3) should be put into effect, you will receive a separate 
written notice of the intention to recoup and the reasons.  Please be advised that CMS may 
charge interest on the amount of the overpayment, consistent with 42 C.F.R.  405.378. In the 
written notice alerting you to the overpayment, you will be given an opportunity for rebuttal in 
accordance with 42 C.F.R.  405.374 from {MAC name}, CMS Medicare Administrative  Contractor (MAC). When the payment suspension has been removed, any money withheld as a 
result of the payment suspension shall be applied first to reduce or eliminate any determined 
overpayment by CMS including any interest assessed under 42 C.F.R.  405.378, and then to 
reduce any other obligation to CMS or to the U.S. Department of Health and Human Services in 
accordance with 42 C.F.R.  405.372(e). In the absence of a legal requirement that the excess be 
paid to another entity, the excess will be released to you. 
 
{Insert the following paragraph if prepayment review is being initiated} Finally, {Name of UPIC 
or MAC}, a CMS {Unified Program Integrity Contractor (UPIC) or MAC}, has initiated a 
process to review your Medicare claims and supporting documentation prior to payment. The 
purpose of implementing this prepayment process is to ensure that all payments made by the 
Medicare program are appropriate and consistent with Medicare rules, regulations and policy. 
The prepayment process is often applied to safeguard Medicare from unnecessary expenditures 
and to ensure that Medicare payments are made for items and services which are reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member. See 42 U.S.C.  1395y(a)(1)(A).  Notification is hereby given that you 
are expected to comply with the prepayment process for claims for all dates and services. 
 
Should you have any questions regarding the status of the suspension, please direct your inquiry 
to [shared mailbox].  Any request to remove the suspension must be submitted through the 
rebuttal process described above. 
 
Sincerely, 
 
Name 
 
 
E. Reliable Information that an Overpayment Exists (RIO) Payment Suspension Extension 
Notice 
 
Date 
 
Name of Addressee (if known)  
Name of Medicare Provider/Supplier  
Address 
City, State Zip 
 
Re:   Notice of Extension of Suspension of Medicare Payments  
Provider/Supplier Medicare ID Number(s):  
Provider/Supplier NPI: 
PSP Number: 
 
Dear {Medicare Provider/Suppliers Name}: 
 
Please be advised that pursuant to 42 C.F.R.  405.372(d), the Centers for Medicare & Medicaid 
Services (CMS) has directed {ENTER UPIC NAME}, CMS Unified Program Integrity 
Contractor, to continue the suspension of your Medicare payments for an additional 180 days 
effective {Enter Date that the payment suspension was to expire}. 
 
The extension of your payment suspension applies to claims in process. We will continue to 
withhold your Medicare payments until an investigation of the circumstances has been 
completed in accordance with 42 C.F.R.  405.372(d). When the payment suspension is  terminated, any money withheld as a result of the payment suspension shall be applied first to 
reduce or eliminate any determined overpayment by CMS including any associated interest 
accrued pursuant to 42 C.F.R.  405.378, and then to reduce any other obligation to CMS or the 
U.S. Department of Health and Human Services. See 42 C.F.R.  405.372(e). In the absence of a 
legal requirement that the excess be paid to another entity, the remainder will be released to you. 
 
Should you have any questions regarding the status of the suspension, please direct your inquiry 
to [shared mailbox].   
 
Sincerely, 
 
Name 
 
 
F. Credible Allegation of Fraud (CAF) Payment Suspension Extension Notice 
 
Date 
 
Name of Addressee (if known)  
Name of Medicare Provider/Supplier  
Address 
City, State Zip 
 
Re:  Notice of Extension of Suspension of Medicare Payments  
Provider/Supplier Medicare ID Number(s):  
Provider/Supplier NPI: 
PSP Number: 
 
Dear {Medicare Provider/Suppliers Name}: 
 
Please be advised that pursuant to 42 C.F.R.  405.371(b), the Centers for Medicare & Medicaid 
Services (CMS) has directed {ENTER UPIC NAME}, CMS Unified Program Integrity 
Contractor, to continue the suspension of your Medicare payments for an additional 180 days 
effective {Enter Date that the payment suspension was to expire}. 
 
The continuation of your payment suspension applies to claims in process. We will continue to 
suspend your Medicare payments until an investigation of the circumstances has been completed 
in accordance with 42 C.F.R.  405.372(c)(2). When the payment suspension is terminated, any 
money withheld as a result of the payment suspension shall be applied first to reduce or eliminate 
any determined overpayment by CMS including any interest assessed under 42 C.F.R.  405.378, 
and then to reduce any other obligation to CMS or the U.S. Department of Health and Human 
Services. See 42 C.F.R.  405.372(e). In the absence of a legal requirement that the excess be 
paid to another entity, the excess will be released to you. 
 
Should you have any questions regarding the status of the suspension, please direct your inquiry 
to [shared mailbox].   
 
Sincerely, 
 
Name 
 
  G. Payment Suspension Termination Notice 
 
USE THIS LETTER IF SENDING PAYMENT SUSPENSION TERMINATION NOTICE 
TO THE PROVIDERS/SUPPLIERS ATTORNEY 
 
Date 
 
Name of Attorney  
Address 
City, State Zip 
 
Re:  Notice of Termination of Suspension of Medicare Payments  
Provider/Supplier Medicare ID Number(s):  
Provider/Supplier NPI: 
Record Identifier(s): 
 
Dear {Medicare Provider/Supplier Attorneys Name}: 
 
The Centers for Medicare & Medicaid Services (CMS) has directed us to terminate the payment 
suspension in effect for Medicare payments to [provider] pursuant to 42 C.F.R.  405.372(c). 
The provider was notified of the results of our review and the overpayment(s) we determined on 
[INSERT DATE]. The overpayment information was forwarded to [INSERT MAC], CMS 
Medicare Administrative Contractor (MAC) for further action. [insert MAC name] will issue the 
overpayment demand letter(s), along with information regarding the providers appeal rights. 
Once the payment suspension is removed, any funds withheld as a result of the payment 
suspension shall be applied first to reduce or eliminate any overpayment by CMS including any 
associated interest accrued pursuant to 42 C.F.R.  405.378 and then to reduce any other 
obligation to CMS or the U.S. Department of Health and Human Services per 42 C.F.R.  
405.372(e). In the absence of a legal requirement that the excess be paid to another entity, the 
excess will be released to the provider.   
 
Please be advised that this action to terminate the payment suspension should not be construed as 
any positive determination regarding the providers Medicare billing and is not an indication of 
government approval of or acquiescence regarding the claims submitted. It does not relieve the 
provider of any civil or criminal liability, and it does not offer a defense to any further 
administrative, civil or criminal actions against the provider. 
 
Sincerely, 
 
Name 
 
 
H. Payment Suspension Termination Notice 
 
USE THIS LETTER IF SENDING PAYMENT SUSPENSION TERMINATION NOTICE 
TO THE PROVIDER/SUPPLIER 
 
Date 
 
Name of Addressee (if known)  
Name of Medicare Provider/Supplier  
Address  City, State Zip 
 
Re:  Notice of Termination of Suspension of Medicare Payments  
Provider/Supplier Medicare ID Number(s):  
Provider/Supplier NPI: 
Record Identifier(s): 
 
Dear {Medicare Provider/Suppliers Name}: 
 
The Centers for Medicare & Medicaid Services (CMS) has directed us to terminate the payment 
suspension in effect for Medicare payments to [provider] pursuant to 42 C.F.R.  405.372(c). 
You were notified of the results of our review and the overpayment(s) we determined on 
[INSERT DATE]. The overpayment information was forwarded to [INSERT MAC], CMS 
Medicare Administrative Contractor (MAC), for further action. [Insert MAC name] will issue the 
overpayment demand letter(s), along with information regarding your appeal rights. Once the 
payment suspension is removed, any funds withheld as a result of the payment suspension shall 
be applied first to reduce or eliminate any overpayment by CMS including any associated 
interest accrued pursuant to 42 C.F.R.  405.378 and then to reduce any obligation to CMS or the 
U.S. Department of Health and Human Services per 42 C.F.R.  405.372(e). In the absence of a 
legal requirement that the excess be paid to another entity, the excess will be released to you. 
 
Please be advised that this action to terminate the payment suspension should not be construed as 
any positive determination regarding your Medicare billing and is not an indication of 
government approval of or acquiescence regarding the claims submitted. It does not relieve you 
of any civil or criminal liability, and it does not offer a defense to any further administrative, 
civil or criminal actions against you. 
  
Sincerely, 
 
Name 
 
16.1 - Referral Fact Sheet Template  
(Rev. 826, Issued: 09-21-18, Effective: 10-22-18, Implementation: 10-22-18) 
 
Confidentiality Notice: This message, including any attachments, is for the sole use of the 
intended recipient(s) and may contain confidential information. Any unauthorized review, use, 
disclosure or distribution is prohibited. If you are not the intended recipient, please contact the 
sender and destroy all copies of the original message. 
 
To: 
OIG/DOJ Contact Information 
 
 
From: 
UPIC Contract Information 
 
REFERRAL FACT SHEET 
 
Table 1:  Case Fact Sheet 
Subject(s)   Name:  of Investigation  Address: 
(list additional     
subjects below  Phone: 
primary subject)   
NPI:  
PTAN:   
Tax ID Number: 
 
Effective Date: 
 
Specialty: 
 
Allegation  This section shall describe the allegations the UPIC has learned during 
Summary  the course of the Lead/Investigation. 
Source   
of Allegation 
Date Complaint   
Received (if 
applicable) 
Dollar Paid for  Total dollars paid to the provider for previous 3 years, and timeframe for 
Previous 36  the calculation 
Months 
Identified  Dollars at Risk, and timeframe for the calculation 
Medicare Program 
Loss 
Identified  UPIC to update this section if theyve identified an actual and/or 
Overpayment(s),  extrapolated overpayment through medical review 
if applicable 
UPIC   
Contact 
Information 
UPIC Case  UCM Number(s) 
Number 
 
 
Narrative 
  Predication 
  History of Non-compliance 
  Previous complaints 
o
  Prior Investigations, Medical Reviews, and/or Administrative Actions 
o
  Previous Law Enforcement Referrals and/or Immediate Advisements 
o
  Previous State Medicaid Investigations and/or Audits 
o
  Previous MAC or UPIC Provider Education 
o
  Investigative Steps 
  Beneficiary Interviews 
o
  Provider Interviews 
o
 
 
Medical Review 
Table 2:  Current/Previous Medical Reviews 
  Postpayment Medical Review 
Timeframe of  Probe or SVRS  Number of  Claim Denial  Identified 
Postpayment  Review  Claims Included  Percentage  Overpayment 
Review  in Review  Amount 
         
         
         
 
Denial Reasons and Applicable Policy References per Review: 
 
Additional Detail Regarding Postpayment Medical Reviews:  
 
 
 
 
Prepayment Medical Review 
Prepayment  Prepayment  Targeted or  If targeted  Number of  Claim Denial 
Review Start  Review End  100%  review,  Claims  Percentage 
Date  Date  Review  provide CPT  Reviewed 
codes  To-Date 
selected for 
review 
           
           
           
 
Denial Reasons and Applicable Policy References per Review: 
 
Additional Detail Regarding Postpayment Medical Reviews:  
 
 
 
Billing Information 
Table 3:  Provider Billing Summary 
Year  HICN Count  Claims  Billed Amount  Paid Amount 
         
         
         
         
Totals:         
 
 
Additional Information   
Table 4: Additional Relevant Information 
Current/Former   
Employees with 
Ownership Interest 
PECOS Information   
Providers Legal   
Counsel  Banking Information   
List any other relevant   
information 
 
 
Recommendations 
 
 
Distribution 
  Listing of all individuals that referral will be sent to (including those that are CCd) 
 
 
Exhibits 
  Provider Enrollment Application(s) 
  Provider Electronic Funds Transfer Agreements 
  Previous complaints related to the subject provider 
  Applicable attestations 
  Provider/staff interview summary report(s) 
  Beneficiary interview summary report(s) 
  Medical Review Findings 
  Provider Overpayment Notices 
  Provider Prepayment Review Notices 
  Provider Payment Suspension Notices 
  Any other applicable exhibits/attachments 
 
Exhibit 17  Signature Attestation Form (for missing or illegible signatures) 
(Rev.) 
  
Exhibit 18 - Corrective Action Reporting Formats 
(Rev. 617, Issued: 10-09-15, Effective: 11-10-15, Implementation: 11-10-15) 
  
A.  Corrective Actions Taken on CMS Identified Vulnerabilities: (A/B)/(DME) MACs 
Contractor Name and Jurisdiction: (To be completed by MAC)  
Date Report Submitted to CMS: (To be completed by MAC) 
 
   
   
 
New Issue  Interim    Final   Additional    Updated 
Issue Description 
Number   Response  Response  Comments    Responses 
 
             
             
             
             
             
                           
 
B.  Overpayment Recovery on OIG Claims Format 
 
Contractor Name and Jurisdiction: (To be completed by MAC)  
Date Report Submitted to CMS: (To be completed by MAC) 
 
Overpayment  OPTIONAL   
Reason for no  Other Additional 
OIG Report Number              R   e  c overy             O   v erpayments  Final Reporting 
review of claims and 
referred or  Date for this audit            C   o mments or 
(e.g. A-01-09-00050)  (in dollars)  no recovery               
uncollectable  (completed by  Actions Taken                 
(completed by MAC)  (completed by  (in dollars)  (com(ipf laeptepdli cbayb Mle)A C)  CMS)  (if applicable) 
MAC)  (completed by MAC)   
           
           
           
           
           
           
           
 
Exhibit 19  Reserved for Future Use   
(Rev.) 
 
 
Exhibit 20  Reserved for Future Use  - (Rev.           ) 
 
Exhibit 21  Regional Home Health Intermediaries/Jurisdictions - (Rev. 3, 11-22-
00) 
 
Associated Hospital Services of Maine 
Connecticut  Maine  Massachusetts 
New Hampshire  Rhode Island  Vermont 
  
Palmetto Government Benefits Administration  
  
Alabama  Arkansas  Florida 
Georgia  Illinois  Indiana 
Kentucky  Louisiana  Mississippi 
New Mexico  North Carolina  Ohio 
Oklahoma  South Carolina  Tennessee 
Texas     
   Blue Cross of California 
  
Alaska  American Samoa  Arizona 
California  Guan  Hawaii 
Idaho  Nevada  Northern Mariana 
Islands 
Oregon  Washington   
 
United Government Services 
Michigan  Minnesota  New Jersey  New York 
Puerto Rico  Virgin Islands  Wisconsin   
  
Wellmark, Inc  
  
Colorado  Delaware  District of  Iowa 
Columbia 
Kansas  Maryland  Missouri  Montana 
Nebraska  North Dakota  Pennsylvania  South Dakota 
Utah  Virginia  West Virginia  Wyoming 
 
Exhibit 22 - Office of Inspector General, Office of Investigations Field Offices  
(Rev. 3, 11-22-00) 
 
Street Address  Mailing Address  States 
BOSTON:   HHS, OS, OIG, OI   Connecticut  
Room 1405   P.O. Box 8767   Maine  
JFK Federal Bldg.   Boston, MA 02114   Massachusetts  
Boston, MA 02203   New Hampshire  
(617) 565-2660   Rhode Island  
Vermont  
NEW YORK   HHS, OS, OIG, OI   New Jersey  
Room 3900 B   P.O. Box 3209   New York  
Federal Building   Church St. Station   Puerto Rico  
New York,  New York, NY 10008  Virgin Islands  
NY  10278  
(212) 264-1691  
PHILADELPHIA   HHS, OS, OIG, OI   Delaware  
Room 4430   P.O. Box 8049   Pennsylvania  
3535 Market Street   Philadelphia, PA  West Virginia  
Philadelphia, PA  19101   Maryland Except:  
19104   - Prince Georges County  
(215) 596-6796   - Montgomery County  
Virginia Except:  
- Fairfax County  
- Arlington County   - City of Alexandria  
- City of Falls Church  
ATLANTA   HHS, OS, OIG, OI   Alabama  
Room 1404   P.O. Box 2288   Florida  
101 Marietta Tower   Atlanta, GA 30301   Georgia  
Atlanta, GA 30323   Kentucky  
(404) 331-2131/2556   Mississippi  
North Carolina  
South Carolina  
Tennessee  
CHICAGO   HHS, OS, OIG, OI   Illinois  
23rd Floor   23rd Floor   Indiana  
105 West Adams St.   105 West Adams  Michigan  
Chicago, IL 60603   Street   Minnesota  
(312) 353- 2740   Chicago, IL 60603   Ohio  
Wisconsin  
Missouri  
Iowa  
DALLAS   HHS, OS, OIG, OI   Arkansas  
Room 4E1B   Room 4E1B   Louisiana  
1100 commerce St.   1100 Commerce St.   New Mexico  
Dallas, TX 75242   Dallas, TX 75242   Oklahoma  
(214) 767-8406   Texas  
DENVER   HHS, OS, OIG, OI   Colorado  
Room 327   1961 Stout Street   Kansas  
1961 Stout Street   Denver, CO 80294- Montana  
Federal Office Bldg.   3546   Nebraska  
Denver, CO 80294- North Dakota  
3546   South Dakota  
(303) 844-5621   Wyoming</>  
Utah  
SAN FRANCISCO   HHS, OS, OIG, OI   Arizona  
Room 174   P.O. Box 42516   California  
50 U.N. Plaza   San Francisco, CA   Guam  
San Francisco, CA  94142-2516   Hawaii  
94102   Nevada  
(415) 556-8880   Samoa  
SEATTLE SUB  HHS, OS, OIG, OI   Alaska  
OFFICE   P.O. Box 61220   Idaho  
Room 209, RX-81   Seattle, WA 98121   Oregon  
2201 Sixth Avenue   Washington  
Seattle, WA 98121  
(206) 442-0547  
WASHINGTON,  HHS, OS, OIG, OI   District of Columbia  
D.C. Field Office   Room 5193 Cohen  Maryland Counties:  
Room 5193 Cohen  Bldg.   - Prince Georges  
Bldg.   330 Independence Av  - Montgomery Counties  
330 Independence Av. SW   - Virginia Counties  
SW   Washington, DC  Virginia Cities  
20201   - Alexandria   Washington, DC  - Falls Church  
20201  
(202) 619-1900  
 
Exhibit 23 - PIM Acronyms - (Rev. 3, 11-22-00) 
 
Acronym   Meaning  
ABG  Arterial Blood Gas 
ABN  Advanced Beneficiary Notice 
AC  Affiliated Contractor 
ADL  Activities of Daily Living 
ADMC  Advance Determination of Medicare Coverage 
AIDE  Home Health Aide 
AKA  Also Known As 
ALJ  Administrative Law Judge 
AMA  American Medical Association 
AoA  Administration on Aging 
ASC  Ambulatory Surgical Center 
AUSA  Assistant United States Attorney 
BESS  Part B Extract Summary System 
BI  Benefit Integrity 
CAC  Carrier Advisory Committee 
CBR  Cost Benefit Ratio 
CFO  Chief Financial Office 
CHAMPUS  Civilian Health and Medical Program of the Uniformed 
Services 
CMD  Contractor Medical Director 
CMN  Certificate of Medical Necessity 
CMP  Civil Monetary Penalty 
CMPL  Civil Monetary Penalties Law 
CMR  Comprehensive Medical Review 
CMS  Centers for Medicare & Medicaid Services 
CO  Central Office 
COB  Coordination of Benefits 
CORF  Comprehensive Outpatient Rehabilitation Facility 
CPE  Contractor Performance Evaluation 
CPT  Current Procedural Terminology 
CWF  Common working File 
DAP  DMERC Advisory Panel  DBA  Doing Business As 
DHHS  Department of Health and Human Services 
DME  Durable Medical Equipment 
DMEPOS  Durable Medical Equipment, Prosthetic, and Orthotic 
Supplier 
DMERC  Durable Medical Equipment Regional Carrier 
DOJ  Department of Justice 
DRG  Diagnosis Related Groups 
DX  Diagnosis 
EMC  Electronic Media Claims 
EOMB  Explanation of Medicare Benefits 
EPO  Epoetin 
ESRD  End Stage Renal Dialysis 
FBI  Federal Bureau of Investigation 
FHIBA  Federal Health Insurance Benefits Accounts 
FI  Fiscal Intermediary 
FID  Fraud Investigation Database 
FMR  Focused Medical Review 
FTE  Full Time Equivalent 
FY  Fiscal Year 
GAO  General Accounting Office 
GPRA  Government Performance Results Act 
GTL   Government Task Leader 
HCFA  Health Care Financing Administration 
HCIS  Healthcare Customer Information System 
HCPCS  Healthcare Common Procedure Coding System 
HHA  Home Health Agency 
HHS  Health and Human Services 
HI  Health Insurance 
HICN  Health Insurance Claim Number 
HIPAA  Health Insurance Portability and Accountability Act of 
1996 
HO  Hearings Officer 
ICN/DCN  Internal Control Number/Document Control Number 
IER  Interim Expenditure Report 
IRP  Incentive Reward Program 
IRS  Internal Revenue Service 
LMRP  Local Medical Review Policy 
MCM  Medicare Carrier Manual  MFCU  Medicaid Fraud Control Unit 
MFIS  Medicare Fraud Information Specialist 
MFSR  Medicare Focused Medical Review Status 
MIM  Medicare Intermediary Manual 
MIP  Medicare Integrity Program 
MIP-PET  Medicare Integrity Program-Provider Education and 
Training 
MR  Medical Review 
MSN  Medicare Summary Notice 
MSP  Medicare Secondary Payer 
MSS  Medical social Services 
N/A  Not Applicable 
NCP  National Coverage Policy 
NMFA  National Medicare Fraud Alert 
NOU  Notice of Utilization 
NPR  National Performance Review 
NSC  National Supplier Clearinghouse 
OCIG  Office of Counsel to the Inspector General 
OCSQ  Office of Clinical Standards and Quality 
OIFO  Office of Investigations Field Office 
OIG  Office of Inspector General 
OIGOAS  Office of Inspector General Office of Audit Services 
OIG/OI  Office of Inspector General Office of Investigations 
OP  Outpatient 
OPT  Outpatient Physical Therapy 
OT  Occupational Therapy 
PAL  Provider Audit List 
PI  Program Integrity 
PIM  Program Integrity Manual 
PIN  Provider Identification Number 
PIP  Periodic Interim Payments 
PM  Program Memorandum 
PM-PET  Program Management-Provider Education and Training 
POC  Plan of Care 
PPAC  Practicing Physicians Advisory Council 
PPS  Prospective Payment System 
PRO  Peer Review Organization 
PRRB  Provider Reimbursement Review Board  PSC  Program Safeguard Contractor 
PS&R  Provider Statistical and Reimbursement 
PT  Physical Therapy 
PTS  Provider Tracking system 
QA  Quality Assurance 
QIO  Quality Improvement Organization 
RBS  Report of Benefit Savings 
RCCO  Regional Chief Counsel's Office 
RHC  Rural Health Clinic 
RHHI  Regional Home Health Intermediary 
RMFA  Restricted Medicare Fraud alert 
RMRP  Regional Medical Review Policy 
RO  Regional Office 
ROM  Range of Motion 
RRB  Railroad Retirement Board 
RT  Record Type 
RVU  Relative Value Unit 
SADMERC  Statistical Analysis Durable Medical Equipment Regional 
Carrier 
SLP  Speech-Language Pathology 
SMI  Supplementary Medical Insurance 
SME  Subject Matter Expert 
SN  Skilled Nursing 
SNF  Skilled Nursing Facility 
SOC  Start of Care 
SSA  Social Security Administration 
SSAFO  Social Security Administration Field Office 
ST  Speech Therapy 
SUR  State Utilization Review Units 
the Act  the Social Security Act 
TOB  Type of Bill 
TPN  Total Parenteral Nutrition 
UPIN  Unique Physician Identification Number 
 
 
Exhibit 25  Procedures and Forms for Obtaining Protected Health 
Information 
(Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
  Office of the Director      U.S. Department of Justice 
Executive Office for United States Attorneys 
Room 2616, RFK Main Justice Building  
950 Pennsylvania Avenue, NW  
Washington, DC 20530 
(202) 514-2121 
 
MEMORANDUM -Sent via Electronic Mail 
 
DATE: April 11, 2003 
 
TO: ALL UNITED STATES A TTORNEYS 
  ALL FIRST ASSISTANT UNITED STATES ATTORNEYS  
  ALL CRIMINAL CHIEFS 
    ALL CIVIL CHIEFS 
 
FROM: Guy A. Lewis 
    Director 
 
SUBJECT: Procedures and Forms for Obtaining Protected Health Information in Law 
Enforcement and Health Oversight Investigations; Guidance Materials Concerning New HIPAA 
Privacy Regulations. 
 
ACTION REQUIRED: Please distribute to all Assistant United States Attorneys. 
 
CONTACT PERSONS: Cam Towers Jones 
   Health Care Fraud Coordinator  
  Legal Programs 
  Telephone: (202) 353-8507 
 
Andrea Gross 
Affirmative Civil Enforcement Coordinator  
Legal Programs 
Telephone: (202) 305-3346 
 
New medical privacy rules (located at 45 C.F .R., Parts 160 and 164) take effect on Monday, 
Apri114, 2003. These rules will affect all Assistant United States Attorneys (AUSAs) who obtain 
medical information in the course of their work. 
 
In order to assist AUSAs, the Executive Office for United States Attorneys (EOUSA) and the 
Civil and Criminal Divisions of the Department of Justice have prepared form materials which 
can be used to obtain medical records in law enforcement and health oversight investigations. 
Attached is a WordPerfect document titled "Updated Process, Model Letters, and Forms to 
Request Protected Health Information Pursuant to the HIPAA Privacy Regulation." This 
document includes (1) a description of the process for obtaining Centers for Medicare and 
Medicaid Services (CMS) data after Apri114, 2003; (2) a form letter to be used in requesting 
information from CMS contractors; (3) a form letter to be used in requesting protected health 
information from entities other than CMS contractors (including federal agencies in affirmative 
civil and criminal health care fraud cases; and (4) potential paragraphs to be inserted in letters, 
subpoenas, or other forms of legal process requesting production of protected health information. 
  EOUSA and the Civil and Criminal Divisions of the Department of Justice have also prepared 
guidance about the regulation in a "question and answer" format. These guidance materials were 
distributed at the recent Health Care Fraud Coordinators Conference at the National Advocacy 
Center. An additional copy is also attached to this memorandum, for your information. 
 
Copies of the documents attached to this memorandum will also be posted on the EOUSA 
ACEO and Health Care Fraud Web Page at: http://www.usa.doj.gov/staffs/lp/ace/. 
 
If you have any questions regarding implementation of the privacy regulations, you may contact 
one of the people listed below: 
 
Dan Anderson (Affirmative Civil) 
Civil Division 
(202) 616-2451 
 
Ian DeWaal (Criminal)  
Criminal Division  
(202) 514-0669 
 
Jim Gilligan (Civil Defensive/Federal Programs) 
Civil Division  
(202) 514-3358 
 
Andrea Gross (Affirmative Civil) 
Executive Office for United States Attorneys  
(202) 305-3346 
 
Cam Towers Jones (Criminal) 
Executive Office for United States Attorneys  
(202) 353-8507 
 
Sherri Keene (Civil DefensiveIFTCA) 
Civil Division  
(202) 616-4272 
 
Karen Morrissette (Criminal) 
Criminal Division  
(202) 514-0640 
 
Attachments 
 
cc: All United States Attorneys' Secretaries 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UPDATED PROCESS, MODEL LETTERS AND FORMS TO 
REQUEST PROTECTED HEALTH INFORMATION PURSUANT 
TO THE PRIVACY ACT AND HIPAA PRIVACY RULE 
 
Table of Contents 
 
Page 2: Updated Process for Law Enforcement Agency Requests to Obtain CMS/Medicare data. 
 
Page 4: Letter to request protected health information from the Centers for Medicare & Medicaid 
Services or from CMSs contractors (disclosure of data in CMS Systems of Records). 
 
Page 6: Letter to request protected health information from other covered entities (including 
other federal agencies in affirmative civil and criminal health care fraud cases). 
 
Page 7: Potential paragraphs to be inserted in letters (or subpoenas, etc) requesting production of 
protected health information. 
 
Page 8: Health oversight  
  Page 9: Required by law 
 
Page 10: Whistleblowers/victims of workplace crime 
 
Page 11: Disclosures for law enforcement purposes pursuant to process and as 
otherwise required by law. 
 
Page 12: Disclosures of information about victims of crimes for law enforcement 
purposes in response to a law enforcement request. 
 
Page 13: Disclosures about victims of abuse, neglect or domestic violence.  
 
Page 14: Locate and Identify 
 
Page 15: Decedents 
 
Page 16: Correctional institutions and other law enforcement custodial situations  
 
Page 17: Judicial/Administrative 
 
Page 18: Minimum Necessary 
 
Page 19: Insert Only When Suspension of Notification to Individual is Desired  
 
Page 20: Patient Authorizations 
 
Page 21: Patient Authorization to Release Medical Information 
 
Page 23: Patient Authorization to Release Psychotherapy Information 
 
 
 
 
Updated Process for Law Enforcement Agency Requests to Obtain CMS/Medicare Data 
 
1.  The law enforcement agency should begin by consulting with the appropriate Medicare 
contractor (usually the Unified Program Integrity Contractor, but possibly also the Carrier, Fiscal 
Intermediary, Quality Improvement Organization, or CMS) to discuss the purpose or goal of the 
data request. To illustrate, are data being sought to assess allegations of fraud; examine billing 
patterns; ascertain dollar losses to the Medicare program for a procedure, service or time period; 
conduct a random sample of claims for medical review, etc? Upon receiving a data request from 
a law enforcement agency, the Medicare contractor (e.g., UPIC) will examine its sources of data 
for most recent 36-month period for the substantive matter/s in question or for the specific period 
requested by the law enforcement agency, if necessary. In consultation with the Medicare 
contractor, the law enforcement agency also should make known the following: 
 
  type of data and fields of information needed 
  name and/or other identifying information for provider/s (e.g., 
 Tax Identification Number, Unique Physican Identification 
 Number, etc.) 
  time period necessary for the inquiry (approximate begin 
and end dates if the conduct is not ongoing currently), and 
   format or medium for data to be provided (i.e., tape, CD-ROM, paper, etc.). 
 
2.  As part of the initial consultation process, the Medicare contractor and law enforcement 
agency should develop appropriate language to insert in the data request standard form letter. 
(A copy of an updated standard form letter from the law enforcement agency to Medicare 
contractor, along with various template paragraphs for insertion in the letter to ensure Privacy 
Act and HIPAA Privacy Rule compliance, are provided as attachments.) After consulting with 
the appropriate Medicare contractor, the law enforcement agency should send the signed 
standard form letter, identifying the appropriate authority under which the information is being 
sought and specifying the details of the request described above, to the Medicare contractor. The 
Medicare contractor will provide the relevant data, reports and findings to the requesting agency 
in the format/s requested within 30 days when data for the most recent 36-month period is being 
sought directly from the Medicare contractor. If it is necessary for the Medicare contractor to 
seek and acquire other data from CMS or another affiliated Medicare contractor, the time period 
required to provide the data to the requesting agency will extend beyond 30 days. (Currently, the 
1
average response period for data requests made to CMS is 14 weeks.)   
 
3.  If appropriate, the Medicare contractor will also use analytic tools to look for other possible 
indicia of fraud in addition to the specific alleged conduct that was the cause of the law 
enforcement agencys data request. 
 
4.  If, in the view of the requesting law enforcement agency, the Medicare contractor, or CMS, 
the Medicare contractors initial 36-month review generally verifies the fraud allegations, or if 
potential fraud is uncovered through the use of analytic tools, and upon a subsequent request, the 
Medicare contractor will conduct a supplemental review of Medicare data. The supplemental 
review will meet the specific needs of the law enforcement agency based on the allegations 
under investigation and/or findings of the initial 36-month review. Such supplemental reviews 
may involve retrieving information from original Carrier and/or Fiscal Intermediary data files, as 
well as the National Claims History (NCH), Common Working File (CWF), or other Medicare 
data files that may be archived in order to cover the complete time frame involved in the 
allegations and/or allowed by the statute of limitations. The time period for fulfilling 
supplemental data requests will be negotiated on a case-by-case basis between CMS and the law 
enforcement agency making the data request. 
 
5.  While steps 1-4 describe the usual process to be followed for handling law enforcement 
agency requests for CMS/Medicare data, exceptions to this process will be necessary on a case- 
by-case basis when the law enforcement agency determines that conducting an initial review of 
the most recent 36-months of data would not be sufficient. For example, exceptions will be 
necessary if: 
 
a.  The most recent 36 months of data would not be helpful to 
the investigation because the fraud being investigated is 
alleged to have occurred prior, or in large part prior to, that 
period. 
 
b.  Changes in the payment system used for the type/s of claims in 
question cause the most current data to be inappropriate for 
attempting to verify allegations of possible fraud that occurred 
under a previous payment system. 
 
c.  The purpose of the data request cannot be met using only the  most recent 36 months of data (e.g., a statistical sampling plan 
that requires more than 36 months of data to implement the 
plan correctly and accurately). 
 
d.  Litigation deadlines preclude conducting an initial review 
followed by a more comprehensive supplemental review. 
 
e.  Items 5 a-d are illustrative not exhaustive. 
 
6.  Each agency (DOJ, FBI, CMS, etc.) will designate a contact person for 
advising their internal agency components and field offices about this updated 
process for making data requests to CMS/Medicare contractors, and for resolving 
any conflicts or disagreements that may occur involving specific requests for 
information.   
             USE DEPARTMENT OF JUSTICE LETTERHEAD 
 
[DATE] 
 
If this request for data is made to a Unified Program Integrity Contractor, Quality Improvement 
Organization (QIO), Fiscal Intermediary (FI), or Carrier, address to: 
 
Name of contact person 
Name of the UPIC, QIO, FI, or Carrier  
Address 
 
and send a cc: to:  Regional Office of the Inspector General 
Director, Benefit Integrity and Law Enforcement Liaison, CMS  
 
If this request for data is made to CMS, address to: 
 
Centers for Medicare & Medicaid Services  
Office of Financial Management 
Program Integrity Group 
Director, Benefit Integrity and Law Enforcement Liaison  
C3-02-16 
7500 Security Blvd 
Baltimore, MD 21244 
 
and send a cc: to:  Regional Office of the Inspector General 
 
 
Re:  Request for disclosure of data in CMS Systems of Records 
 
Dear [insert name]: 
 
  This letter is to request your assistance in obtaining CMS data from the [insert file name] 
on [insert type of data needed and providers for which data is needed] for claims during the 
following time period: [insert time period]. Please provide this data in [specify format, i.e., CD, 
tape, disk, paper, etc.] directly to [insert name, address, telephone number, and role of the person 
in connection with the case]. 
 
Instructions to DOJ attorney or investigator filling out letter: INSERT APPROPRIATE 
PARAGRAPHS FROM THE ALTERNATIVES, ATTACHED, Beginning at page 7. 
 
  Additionally, to ensure Privacy Act compliance, CMS has issued and published routine 
uses authorizing disclosure of data in CMS systems of records for such purposes. See 63 Federal 
 
 
   
Register 38414, July 16, 1998. The focus of our examination is the following: [insert general 
description of the nature of the law enforcement or health oversight activity being pursued].  
 
  You can be assured that the DOJ will take all appropriate measures to ensure that this 
data will be maintained and used in compliance with Section VI (Confidentiality Procedures) of 
the Health Care Fraud and Abuse Control Program Guidelines agreed to by the Attorney General 
and the Secretary of the Department of Health and Human Services under the Health Insurance 
Portability and Accountability Act of 1996. 
 
  I understand that CMS does not commit to processing my request if the estimated cost of 
doing so exceeds $200,000, and that a CMS representative will contact me if the estimated cost 
exceeds that amount. Additionally, I understand that CMS officials may intercede should a DOJ 
request for CMS data create a substantial resource impact on the data processing capabilities of 
the CMS Data Center, a Medicare Fiscal Intermediary, Carrier, Unified Program Integrity 
Contractor, QIO, or other contractor. For requests initiated by the FBI or United States 
Attorneys offices, discussions to resolve such resource issues will be conducted between the 
appropriate CMS official and the appropriate FBI agent or Assistant United States Attorney 
(AUSA), or if necessary, the appropriate FBI or AUSA supervisor. For requests initiated by DOJ 
headquarters, or where regional resolution has been unsuccessful, CMS officials may refer such 
resource issues to the appropriate DOJ headquarters official. 
 
Thank you for your assistance with this matter. Please call me at [insert phone #] if you 
have any questions about this request. 
 
Sincerely, 
 
 
[name, title, and office of DOJ official] 
 
   
 
 
   
USE DEPARTMENT OF JUSTICE LETTERHEAD 
MODIFY AS APPROPRIATE FOR YOUR INVESTIGATION AND FOR THE 
PARTICULAR RECIPIENT OF THE REQUEST (E.G., SUBPOENAED 
PERSON) 
 
[DATE] 
 
 
 
Re: Request for production of protected health information 
 
Dear [insert name]: 
 
  This letter is to request that you produce information/data from [source of records] on 
[insert type of data/information needed and providers for which information is needed] for 
claims during the following time period: [insert time period]. Please provide this 
information/data in [specify format, i.e., CD, tape, disk, paper, etc.] directly to [insert name, 
address, telephone number, and role of the person in connection with the case.] 
 
Instructions to DOJ attorney or investigator filling out letter: INSERT APPROPRIATE 
PARAGRAPHS FROM THE ALTERNATIVES, ATTACHED, Beginning at page 7. 
 
  Thank you for your assistance with this matter. Please call me at [insert phone #] if you 
have any questions about this request. 
 
 
Sincerely, 
 
 
[name, title, office of DOJ official] 
 
 
   
 
 
   
POTENTIAL PARAGRAPHS TO BE INSERTED IN LETTERS (OR SUBPOENAS, ETC) 
REQUESTING PRODUCTION OF PROTECTED HEALTH INFORMATION. PLEASE 
READ ALL PARAGRAPHS AND ENSURE THAT YOU HAVE INCLUDED ALL 
NECESSARY PROVISIONS. 
 
HEALTH OVERSIGHT 
 
 
You are requested to produce this information to the Department of Justice in its capacity as a 
health oversight agency, and this information is necessary to further health oversight activities. 
45 C.F.R. 164.512(d); 45 C.F.R. 164.501. 
 
 
   
REQUIRED BY LAW 
 
 
  The information sought in this request is required by law to be produced to the 
Department of Justice, pursuant to   , (cite 
the applicable law or reference the legal process that is attached to this document.) Disclosure is 
therefore permitted under 45 C.F.R. 164.512(a). 
 
(NOTE TO DRAFTER: IF THIS REQUEST ALSO FALLS WITHIN THE PROVISIONS OF 
45 C.F.R. 164.512 (c), (e), OR (f). THEN YOU MUST ALSO MEET THE REQUIREMENT 
OF THAT SUBSECTION AND YOU MUST ALSO ASSERT THAT YOU HAVE MET THAT 
REQUIREMENT. 
 
IF YOUR REQUIRED BY LAW REQUEST IS MADE IN A HEALTH OVERSIGHT 
CAPACITY, YOU SHOULD ASSERT THIS FACT SO THAT THE RECIPIENT OF THE 
REQUEST UNDERSTANDS THAT NO ADDITIONAL REQUIREMENTS NEED BE MET. 
45 C.F.R. Section 164.512(d)(1)) 
 
 
   
WHISTLEBLOWERS/VICTIMS OF WORKPLACE CRIME 
  (See 65 Fed. Reg. 250, page 82492) 
 
  This request for information is made to you in your capacity as a whistleblower, 
described at 45 C.F.R. 164.502(j)(l)(i) as [an individual who] believes in good faith that the 
covered entity has engaged in conduct that is unlawful or otherwise violates professional or 
clinical standards, or that the care, services, or conditions provided by the covered entity 
potentially endangers one or more patients, workers, or the public. . . You are requested to 
produce the information described in Attachment A, hereto, to the Department of Justice in its 
capacity as a health oversight agency, as permitted by 45 C.F.R. 164.502(j)(l)(ii). 
 
 
OR 
 
  This request for information is made to you in your capacity as a victim of a criminal act 
and a member of the workforce of a covered entity. You are providing information about the 
suspected perpetrator of the criminal act, and should limit your disclosure to the following 
information: a) name and address; b) date and place of birth; c) social security number; d) ABO 
blood type and Rh factor; e) type of injury; f) date and time of treatment; g) date and time of 
death; h) distinguishing physical characteristics. This request is made pursuant to 45 C.F.R. 
164.502(j)(2). 
 
 
   
Disclosures for law enforcement purposes pursuant to  
process and as otherwise required by law (45 CFR 164.512(f)(1)) 
 
  The undersigned hereby represents that this request for protected health information is 
made by a law enforcement agency [specify agency] for law enforcement purposes and is 
permitted by 45 CFR 164.512(f)(1) in that: 
 
[INSERT PARAGRAPH (i), (iiA), (iiB), OR (iiC) BELOW] 
 
(i)  the disclosure is required by law [specify the law];  
 
OR 
 
(iiA) the disclosure is in compliance with and limited by the relevant requirements of a court order 
or court-ordered warrant, or a subpoena or summons issued by a judicial officer [attach relevant 
copies]; 
 
OR 
 
(iiB) the disclosure is in compliance with and limited by the relevant requirements of a grand 
jury subpoena [attach copy]; 
 
OR 
 
(iiC) the disclosure is in compliance with and limited by the relevant requirements of an 
administrative request, including an administrative subpoena or summons, a civil or authorized 
investigative demand, or similar process authorized by law [attach copy]. The undersigned 
further represents that the information sought is relevant and material to a legitimate law 
enforcement inquiry, the request is specific and limited in scope to the extent reasonably 
practicable in light of the purpose for which the information is sought, and de-identified 
information could not reasonably be used. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
Disclosures of information about victims of crimes for law enforcement  
purposes in response to a law enforcement request (45 CFR 164.512(f)(3)) 
 
 
  The undersigned hereby represents that this request for protected health information is 
made by a law enforcement agency [specify agency] for law enforcement purposes and is 
permitted by 45 CFR 164.512(f)(3) in that the requested information is about an individual who 
is or is suspected to be a victim of a crime and that: 
 
[INSERT PARAGRAPH (i) OR (ii) BELOW] 
 
(i) the individual has agreed to the disclosure [specify manner of agreement and/or attach written 
evidence of agreement]; (examples at page 23) 
 
OR 
 
(ii) the covered entity is unable to obtain the individuals agreement because of incapacity or 
other emergency circumstance [specify nature of incapacity or emergency circumstance]. The 
undersigned law enforcement official represents that: the requested information is needed to 
determine whether a violation of law by a person other than the victim has occurred, and that 
such information is not intended to be used against the victim; immediate law enforcement 
activity which depends upon the disclosure would be materially and adversely affected by 
waiting until the individual is able to agree to the disclosure. The undersigned further asserts that 
the circumstances are such that the covered entity, in the exercise of its professional judgment, 
should determine that the disclosure is in the best interests of the individual. 
 
 
   
Disclosures about victims of abuse, neglect or domestic violence (45 C.F.R. 164.512(c)) 
 
 
If the covered entity reasonably believes that the individual (whose personally 
identifiable health information is requested) is a victim of abuse, neglect or domestic violence, 
this request for information is permitted by 45 C.F.R. 164.512(c)(1) because the disclosure is to  
____________________, which is a government agency authorized by law to receive reports of 
such abuse, neglect, or domestic violence, and: 
 
[INSERT PARAGRAPH (i) or (ii) or either (iiiA) or (iiiB) below] 
 
i)  the disclosure is required by law [specify the law] and complies with and is limited to the 
relevant requirements of such law; 
 
OR 
 
ii) the individual has agreed to the disclosure [specify manner of agreement and/or attach written 
evidence of agreement]; 
 
OR, EITHER 
 
iiiA) the disclosure is expressly authorized by statute or regulation, namely, [specify the law] and 
the covered entity believes the disclosure is necessary to prevent serious harm to the individual 
or other potential victims; 
 
OR 
 
iiiB) the disclosure is expressly authorized by statute or regulation [specify the law] and the 
individual is unable to agree because of incapacity [specify nature of incapacity], and the 
recipient law enforcement or public official authorized to receive the report [specify the agency] 
hereby represents that the protected health information which is sought is not intended to be used 
against the individual.  The   [specify agency] further represents that an 
immediate enforcement activity depends on the disclosure and would be materially and adversely 
affected by waiting until the individual is able to agree to the disclosure. 
 
 
   
Locate and Identify 
 
 
  This request for protected health information is made by a law enforcement agency 
pursuant to the provisions of 45 C.F.R. 164.512(f)(2) which permit the disclosure of the 
enumerated limited information for identification and location purposes. 
 
  A covered entity is permitted to make a disclosure to a law enforcement officer under this 
paragraph for the purpose of identifying or locating a suspect, fugitive, material witness or a 
missing person. The following information may be disclosed: (A) name and address; (B) date 
and place of birth; (C) social security number; (D) ABO blood type and rh factor; (E) type of 
injury; (F) date and time of treatment; (G) date and time of death (if applicable); (H) a 
description of distinguishing physical characteristics, including, height, weight, gender, race, hair 
and eye color, presence or absence of facial hair (beard or moustache), scars and tattoos. 
 
 
 
   
Decedents 
 
(NOTE: This section of the regulation can only be used to permit a disclosure to a coroner, 
pursuant to a request by a coroner. Therefore, it will seldom be used in connection with requests 
in federal investigations, and even in those cases, the request must originate from a coroner.) 
 
 
  This request for protected health information is made by a [coroner] [medical examiner] 
pursuant to the provisions of 45 C.F.R. 164.512(g) which permit a covered entity to disclose 
protected health information to a coroner or medical examiner for the purpose of identifying a 
deceased person, determining a cause of death, or other duties as authorized by law. 
 
 
 
   
Correctional institutions and other law enforcement custodial situations 
 
  This request for protected health information is made by a [correctional institution][law 
enforcement agency] with lawful custody of [fill in name of prisoner/detainee].  The undersigned 
represents that the protected health information is necessary for (check all that apply): ( ) the 
provision of health care to this individual; ( ) the health and safety of this individual or other 
inmates; ( ) the health and safety of the custodial officers or employees of, or others at, the 
correctional institution; ( ) the health and safety of this individual and custodial officers, or other 
persons responsible for transporting this inmate, or this individual's transfer from one institution, 
facility or setting to another; ( ) law enforcement on the premises of the correctional institution; 
or ( ) the administration and maintenance of the safety, security, and good order of the 
correctional institution. The requested disclosure of protected health information is permitted by 
the provisions of 45 C.F.R. 164.512(k)(5). 
 
 
 
   
Judicial/Administrative 
 
  The Department of Justice, through its undersigned representative, requests this 
information for judicial and administrative proceedings. Consistent with 45 C.F.R. 164.512(e), 
this request is [Insert one of the following alternatives]: 
 
A.  Pursuant to the order of [a court] [an administrative tribunal], and the only information 
disclosed is the protected health information expressly authorized by the order [attach copy of 
order where appropriate]; OR 
 
Pursuant to a subpoena, discovery request, or other lawful process, that is not accompanied by a 
court-order or order of an administrative tribunal, and 
 
Reasonable efforts have been made to ensure that the individual whose information is sought has 
been given notice of the request by way of a good faith attempt to provide written notice to the 
individual, as shown by the accompanying documentation [attach copy of notice to individual 
and affidavit of service]; and 
 
The notice to the individual included sufficient information about the underlying litigation or 
proceeding to permit the individual to raise an objection to the [court] [administrative tribunal]; 
and 
 
The time for the individual to raise objections to the [court] [administrative tribunal] has expired, 
and 
 
No objections were filed, or 
 
All objections filed by the individual have been resolved by the [court] [administrative tribunal] 
and the disclosures sought are consistent with such resolution. 
 
OR [alternate, if patient has not been given notice]: 
 
Reasonable efforts have been made to secure a qualified protective order that meets the 
requirements set forth in 45 C.F.R.. 164.512(e)(1)(v), and: 
 
The parties to the underlying dispute which precipitated this request for protected health 
information have agreed to a qualified protective order and have presented it to the [court] 
[administrative tribunal] with jurisdiction over the dispute [attach copy of proposed protective 
order, if appropriate], OR 
 
We have requested a qualified protective order from the [court] [administrative tribunal] with 
jurisdiction over the dispute [attach copy of proposed protective order, if appropriate]. 
 
 
 
 
 
 
   
Minimum Necessary 
 
 
(NOTE: Do not use this language when the request is authorized by the patient or required by 
law, because the minimum necessary standard does not apply to disclosures which are 
required by law. 65 Fed. Reg. 250, 82530, 82600, 82715); 
45 C.F.R. 164.502(b)(2)(v) 
 
 
 
 
  The information sought in this request is the minimum necessary to accomplish the 
intended purpose of the . . . request. 45 C.F.R. 164.502(b)(2)(v). (See 65 Fed. Reg. 82530 A 
covered entity is not required to second guess the scope or purpose of the request...) 
 
 
   
Insert Only When Suspension of Notification to Individual is Desired 
 
 
The protected health information concerning the patients  
 
  [INSERT EITHER PARAGRAPH (i) OR (ii) BELOW] 
 
(i) listed on Attachment A, hereto, which your organization disclosed to the Department 
of Justice on   (specify date) in response to a 
 
OR 
 
  (ii) which is disclosed in response to the accompanying 
 
 
    (insert type of request, e.g. grand jury subpoena, other subpoena, 
oral request, other) was requested in furtherance of a federal   law enforcement/health 
oversight (choose one) investigation. An accounting of this disclosure to the individuals 
concerned would, in this instance, be reasonably likely to impede the [Department of Justices] 
activities   45 C.F.R. Section 164.528(a)(2)(i). Therefore, pursuant to this 
request and as required by the provisions of 45 C.F.R. Sec. 164.528(a)(2), you must suspend the 
individual(s) right to receive an accounting of this disclosure of protected health information for 
(months/years). 
 
 
   
PATIENT AUTHORIZATIONS 
 
 
  You are requested to release records pertaining to the individual(s) indicated on the 
enclosed form(s) titled "Authorization to Release Medical Information." 
 
  NOTE: 
 
(1) Your state laws may contain medical record release requirements other than those set 
out on this form. 
 
(2)  If psychotherapy notes are requested, please use the separate authorization for this 
specific purpose. The regulations provide that an authorization for disclosure of 
psychotherapy notes may only be combined with another authorization for a use or 
disclosure of psychotherapy notes. 45 CFR 164.508(b)(3)(ii). 
 
 
   
PATIENT AUTHORIZATION TO RELEASE MEDICAL INFORMATION 
 
 
TO:    PATIENT:    RELEASE TO: 
 
[Name of person or class of  NAME:  Representatives of the 
persons authorized to make    United States Attorneys Office 
disclosure]  BIRTH DATE:  or Department of Justice 
 
 
INFORMATION REQUESTED: I request and authorize the above-named person or class of 
persons to release the information specified below to representatives of the United States 
Attorneys Office or the Department of Justice. Any and all records regarding treatment of 
    including but not limited to: 
 
(1) Copy of complete chart, progress notes & interview notes, discharge 
summaries, operative reports, x-ray & all imagery, laboratory tests, pathology 
tissue, and all diagnostic studies whether in electronic data or other format. 
 
(2)  Billing records 
 
PURPOSE(S) OR NEED FOR WHICH INFORMATION IS TO BE USED: 
 
[Include case name or identify administrative claim] 
 
 
 
CERTIFICATION: I certify that this request has been made voluntarily and that the information 
given above is accurate to the best of my knowledge. I understand that I may revoke this 
Authorization at any time, provided that revocation is in writing, except to the extent that action 
has already been taken in reliance this Authorization. I understand that the doctor, health care 
provider, or health plan from whom my medical information is requested in this Authorization, 
may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign 
this authorization. I understand the potential for the information disclosed pursuant to this 
Authorization to be subject to redisclosure by the recipient and no longer be protected by the 
Standards for Privacy of Individually Identifiable Health Information, set forth at 45 CFR Parts 
160 and 164. 
 
 
EXPIRATION: 
 
Check one: 
 
    This Authorization will automatically expire upon completion of the litigation [provide case 
name and number]     now pending in U.S. 
District Court for the   District of     . 
 
     This Authorization will automatically expire upon completion of the administrative claim of 
 
 
   
  filed on   . 
 
     This Authorization shall be effective until   . 
 
OTHER CONDITIONS: 
 
   x A copy of this Authorization or my signature thereon shall be used with the same 
effectiveness as an original. 
   x Communications between provider and any representative of the U.S. Attorney's 
Office/Department of Justice are authorized. 
 
 
 
SIGNATURE OF PATIENT: 
 
 
OR PERSON AUTHORIZED TO SIGN FOR 
PATIENT:*    
 
 
 
 
__________________                                              ______________________ 
 
MONTH/DAY/YEAR    PRINT OR TYPE NAME 
 
 
*Provide basis of Authorization:    
. 
 
 
   
 
PATIENT AUTHORIZATION TO RELEASE PSYCHOTHERAPY INFORMATION 
 
 
TO:    PATIENT:  RELEASE TO: 
 
[Name of person or class of  NAME:                  Representatives of the 
persons authorized to make    United States Attorneys Office 
disclosure]  BIRTH DATE:  or Department of Justice 
 
 
 
INFORMATION REQUESTED: I request and authorize the above-named person or class of 
persons to release the information specified below to representatives of the United States 
Attorneys Office or the Department of Justice. Any and all records regarding treatment of  
           including but not limited to: 
 
1.  All records of psychological or psychiatric testing or treatment, including complete chart, 
audio and visual recordings, and psychotherapy notes, and 
 
2.   Billing records. 
 
PURPOSE(S) OR NEED FOR WHICH INFORMATION IS TO BE USED: 
 
[Include case name or identify administrative claim] 
 
 
 
CERTIFICATION: I certify that this request has been made voluntarily and that the information 
given above is accurate to the best of my knowledge. I understand that I may revoke this 
Authorization at any time, provided that revocation is in writing, except to the extent that action 
has already been taken in reliance this Authorization. I understand that the doctor, health care 
provider, or health plan from whom my medical information is requested in this Authorization, 
may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign 
this authorization. I understand the potential for the information disclosed pursuant to this 
Authorization to be subject to redisclosure by the recipient and no longer be protected by the 
Standards for Privacy of Individually Identifiable Health Information, set forth at 45 CFR Parts 
160 and 164. 
 
EXPIRATION: 
 
Check one: 
 
 
 
   
    This Authorization will automatically expire upon completion of the litigation [provide case 
name and number]                                                  now pending in U.S. District 
Court for the   District of     . 
 
This Authorization will automatically expire upon completion of the administrative claim of 
                                                                   filed on   . 
 
     This Authorization shall be effective until   . 
 
 
OTHER CONDITIONS: 
 
   x A copy of this Authorization or my signature thereon shall be used with the same 
effectiveness as an original. 
   x Communications between provider and any representative of the U.S. Attorney's 
Office/Department of Justice are authorized. 
 
 
 
SIGNATURE OF PATIENT: 
 
 
OR PERSON AUTHORIZED TO SIGN FOR 
PATIENT:*    
 
 
 
 
  ____________________        _______________________ 
     
MONTH/DAY/YEAR  PRINT OR TYPE NAME 
 
 
*Provide basis of 
Authorization:   . 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
   
     This Authorization shall be effective until _____________________________.                                                     
 
 
OTHER CONDITIONS:   
 
   x    A copy of this Authorization or my signature thereon shall be used with the same 
effectiveness as an original.  
   x    Communications between provider and any representative of the U.S. Attorney's 
Office/Department of Justice are authorized. 
 
                                                                                                                                                                            
 
SIGNATURE OF PATIENT: 
__________________________________________________________________                                    
 
OR PERSON AUTHORIZED TO SIGN FOR 
PATIENT:*___________________________________________ 
 
 
__________________    
 ______________________________
______ 
MONTH/DAY/YEAR  PRINT OR TYPE NAME   
 
 
*Provide basis of 
Authorization:__________________________________________________________. 
     
EXHIBIT 26 - DOJ Report (Excel Spreadsheet) 
(Rev. 16, 11-28-01) 
 
               
    Date of  Nature   DOJ       Date of 
Contractor Identification  DOJ   of   Tracking  Cost SBR  SBR  
Name  Number  Request Request #   to   Y or Submission 
(if  Fill  N 
provided) 
               
               
               
 
Exhibit 27 - National Medicare Fraud Alert 
(Rev. 10383; Issued: 10-09-2020; Effective: 11-10-2020; Implementation: 11-10-
2020) 
 
NATIONAL MEDICARE FRAUD ALERT TEMPLATE 
 
Distribution of this Fraud Alert is Limited to the Following 
Audience: CMS regional offices, Unified Program Integrity 
Contractors, quality improvement organizations, Medicaid 
Fraud Control units, the Office of Inspector General, the 
Defense Criminal Investigation Service, the Department of 
Justice, the Federal Bureau of Investigation, U.S. Attorney 
offices, U.S. Postal Inspectors, Internal Revenue Service, State 
Surveyors, State Attorneys General, and the State Medicaid 
Program Directors 
 
SUBJECT: 
 
ACTIVITY: 
 
SOURCE: 
 
DISCOVERY: 
 
DETECTION METHODOLOGY: 
 
UCM CASE (S): 
 
STATUS: 
 
     
CONTACT: 
 
 
THIS ALERT IS PROVIDED FOR EDUCATIONAL AND 
INFORMATIONAL PURPOSES ONLY. IT IS INTENDED TO ASSIST 
PARTIES IN OBTAINING ADDITIONAL INFORMATION 
CONCERNING POTENTIAL FRAUD AND ABUSE AND TO ALERT 
AFFECTED PARTIES TO THE NATURE OF THE SUSPECTED 
FRAUD. IT IS NOT INTENDED TO BE USED AS A BASIS FOR 
DENIAL OF CLAIMS OR ANY ADVERSE ACTION AGAINST ANY 
PROVIDER OR SUPPLIER. SUCH DECISIONS MUST BE BASED ON 
FACTS DEVELOPED INDEPENDENT OF THIS ALERT. 
 
CMS NMFA                DATE 
 
Exhibit 28 - Restricted Medicare Fraud Alert 
(Rev. 10383; Issued: 10-09-2020; Effective: 11-10-2020; Implementation: 11-10-
2020) 
 
RESTRICTED MEDICARE FRAUD ALERT TEMPLATE 
 
 
THIS ALERT IS CONFIDENTIAL. It is not intended to be used as 
a basis for the denial of any claim or adverse action against 
any provider. Such decisions must be based on facts 
independent of this alert. 
 
Distribution is Limited to the Following Audience: CMS 
regional offices, Unified Program Integrity Contractors, quality 
improvement organizations, Medicaid Fraud Control units, the 
Office of Inspector General, the Defense Criminal 
Investigation Service, the Department of Justice, the Federal 
Bureau of Investigation, U.S. Attorney offices, U.S. Postal 
Inspector offices, and the Internal Revenue Service, and the 
State Medicaid Program Integrity Directors 
 
SUBJECT: 
 
ACTIVITY: 
 
SOURCE: 
 
DISCOVERY: 
 
     
DETECTION METHODOLOGY: 
 
UCM CASE (S): 
 
STATUS: 
 
CONTACT: 
 
NOTICE: THIS FRAUD ALERT CONTAINS CONFIDENTIAL 
INFORMATION EXEMPT FROM DISCLOSURE UNDER THE 
FREEDOM OF INFORMATION ACT PURSUANT TO EXEMPTION 
(b) (2), (b)(5) AND (b)(7)(E) OF THE FOIA. ITS CONTENTS 
SHOULD NOT BE REPRODUCED OR RELEASED TO ANY OTHER 
PARTY WITHOUT WRITTEN APPROVAL OF THE BENEFITS 
INTEGRITY STAFF. DISCLOSURE TO UNAUTHORIZED PERSONS 
IS PROHIBITED AND MAY BE IN VIOLATION OF THE CRIMINAL 
PROVISIONS OF THE PRIVACY ACT. 
 
THIS ALERT IS PROVIDED FOR EDUCATIONAL AND 
INFORMATIONAL PURPOSES ONLY. IT IS INTENDED TO ASSIST 
PARTIES IN OBTAINING ADDITIONAL INFORMATION 
CONCERNING POTENTIAL FRAUD AND ABUSE AND TO ALERT 
AFFECTED PARTIES TO THE NATURE OF THE SUSPECTED 
FRAUD. IT IS NOT INTENDED TO BE USED AS A BASIS FOR 
DENIAL OF CLAIMS OR ANY ADVERSE ACTION AGAINST ANY 
PROVIDER OR SUPPLIER. SUCH DECISIONS MUST BE BASED ON 
FACTS DEVELOPED INDEPENDENT OF THIS ALERT. 
 
CMS RMFA                 DATE 
 
Exhibit 29  Reserve for Future Use 
(Rev. 220, Issued: 08-24-07, Effective: 09-03-07, Implementation: 09-03-07) 
 
Exhibit 30 - Treatment Codes 
(Rev. 23, 03-18-02) 
 
A.  Skilled Nursing 
 
These represent the services to be performed by the nurse. Services performed by the 
patient or other person in the home without the teaching or supervision of the nurse are 
not coded. The following is a further explanation for each service: 
 
A1 * Skilled Observation  Includes all skilled observation and 
and Assessment  assessment of the patient where the 
(Inc. V.S.,   physician determines that the patient's 
     
Response to Med.,  condition is such that a reasonable 
etc)   probability exists that significant changes 
may occur which require the skills of a 
licensed nurse to supplement the 
physician's personal contacts with the 
patient. (See 3117.4.A.)  
A2  Foley Insertion  Insertion and/or removal of the Foley 
catheter by nurse.  
A3  Bladder Instillation   Instilling medications into the bladder.  
A4*  Open Wound  Includes irrigation of open, postsurgical 
Care/Dressing   wounds, application of medication and/or 
dressing changes. Does not include 
decubitus care. Describe dimension of 
wound (size and amount and type of 
drainage) on an addendum, when 
necessary. See A28 for observation 
uncomplicated surgical incision.  
A5*  Decubitus Care  Includes irrigation, application of 
(Partial tissue loss  medication and/or dressing changes to 
with signs of  decubitus. The agency describes size 
infection   (depth and width) and appearance on an 
or full thickness  addendum when necessary. Use this code 
tissue loss, etc.)   only if the decubitus being treated presents 
the following characteristics:  
1 -- Partial tissue loss with signs of 
infection such as foul odor or purulent 
drainage;  
2 -- Full thickness tissue loss that involves 
exposure of fat or invasion of other tissue 
such as muscle or bone.  
For care of decubitus not meeting this 
definition, see A29.  
A6*  Venipuncture   The HHA specifies the test and frequency 
to be performed under physician's orders.  
A7*  Restorative Nursing  Includes exercises, transfer training, 
carrying out of restorative program 
ordered by the physician. This may or may 
not be established by a physical therapist. 
This code is not used to describe non-
skilled services (e.g., routine range of 
motion exercises).  
A8  Post Cataract Care   Includes observation, dressings, teaching, 
etc., of the immediate postoperative 
cataract patient. (See MIM 3117.4.A.)  
     
A9   Bowel/Bladder  Includes training of patients who have 
Training   neurological or muscular problems or 
other conditions where the need for bowel 
or bladder training is clearly identified. 
(See MIM 3114.4.E.1.)  
A10  Chest Physio  Includes breathing exercises, postural 
(Including   drainage, chest percussion, conservation 
postural drainage)   techniques, etc.  
A11  Adm. of Vitamin B- Administration of vitamin B-12 
12   preparation by injection for conditions 
identified in Medicare guidelines. (See 
MIM 3117.4.)  
A12  Adm. Insulin   Preparation of insulin syringes for 
administration by the patient or other 
person, or the administration by the nurse. 
A13  Adm. Other  Administration of any injection other than 
IM/Subq   vitamin B-12 or insulin ordered by the 
physician.  
A14  Adm. IVs/ Clysis   Administration of intravenous fluids or 
clysis or intravenous medications.  
A15  Teach Ostomy or  Teaching the patient or other person to 
Ileo conduit care   care for a colostomy, ileostomy or 
ileoconduit or nephrostomy.  
A16  Teach Nasogastric  Teaching the patient or other person to 
Feeding   administer nasogastric feedings. Includes 
teaching care of equipment and 
preparation of feedings.  
A17  Reinsertion  Includes changing the tube by the nurse.  
Nasogastric  
A18  Teach Gastrostomy  Teaching the patient or other person to 
Feeding   care for gastrostomy and administer 
feedings. Includes teaching care of 
equipment and preparation of feedings.  
A19  Teach Parenteral  Teaching the patient and/or family to 
Nutrition   administer parenteral nutrition. Includes 
teaching aseptic technique for dressing 
changes to catheter site. Agency 
documentation must specify that this 
service is necessary and does not duplicate 
other teaching.  
A20  Teach Care of Trach  Teaching the patient or other person to 
care for a tracheostomy. This includes care 
of equipment.  
     
A21  Adm. Care of Trach  Administration of tracheostomy care by 
the nurse, including changing the 
tracheostomy tube and care of the 
equipment.  
A22  Teach Inhalation Rx.  Teaching patient or other person to 
administer therapy and care for equipment.  
A23*  Adm. Inhalation Rx  Administration of inhalation treatment and 
care of equipment by the nurse.  
A24  Teach Adm. of  Teaching patient or other person to 
Injection   administer an injection. Does not include 
the administration of the injection by the 
nurse (see A11, A13) or the 
teaching/administration of insulin. (See 
A12, A25.)  
A25  Teach Diabetic Care  Includes all teaching of the diabetic patient 
(i.e., diet, skin care, administration of 
insulin, urine testing).  
A26  Disimpaction/F.U.  Includes nursing services associated with 
Enema   removal of an impaction. Enema 
administration in the absence of an 
impaction only if a complex condition 
exists - e.g., immediate postoperative 
rectal surgery.  
A27*  Other (Spec. Under  Includes any skilled nursing or teaching 
Orders)   ordered by the physician and not identified 
above. The agency specifies what is being 
taught in Item 21 (Form CMS-485).  
A28*  Wound  Skilled observation and care of surgical 
Care/Dressing   incision/suture line including application 
Closed  of dry sterile dressing. (See A4.)  
Incision/Suture Line  
A29*  Decubitus Care   Includes irrigation, application of 
medication and/or dressing changes to 
decubitus/other skin ulcer or lesion, other 
than that described in A5. The HHA 
describes size (depth and width) and 
appearance on the addendum.  
A30  Teach Care of Any  Teaching patient or other person to care 
Indwelling Catheter  for indwelling catheter.  
A31  Management and  The complexity of necessary unskilled 
Evaluation of Patient services require skilled management of a 
Care Plan   registered nurse to ensure that these 
services achieve their purpose, and to 
     
promote the beneficiary's recovery and 
medical safety.  
A32* Teaching and  Specify under physician orders. 
Training (other) 
(spec. under Orders) 
 
* Code which requires a more extensive descriptive narrative for physicians orders. 
 
B.  Physical Therapy (PT) 
 
These codes represent all services to be performed by the physical therapist. If services 
are provided by a nurse, they are included under A7. The following is a further 
explanation of each service: 
 
B1  Evaluation   Visit(s) made to determine the patient's condition, 
physical therapy plans and rehabilitation 
potential; to evaluate the home environment to 
eliminate structural barriers and to improve safety 
to increase functional independence (ramps, 
adaptive wheelchair, bathroom aides).  
B2  Therapeutic  Exercises designed to restore function. Specific 
Exercise   exercise techniques (e.g., Proprioceptive 
Neuromuscular Facilitation (PNF), Rood, 
Brunstrom, Codman's, William's) are specified. 
The exercise treatment is listed in the medical 
record specific to the patient's condition, manual 
therapy techniques, which include soft tissue and 
joint mobilization to reduce joint deformity and 
increase functional range of motion.  
B3  Transfer  To evaluate and instruct safe transfers (bed, bath, 
Training   toilet, sofa, chair, commode) using appropriate 
body mechanics, and equipment (sliding board, 
Hoyer lift, trapeze, bath bench, wheelchair). 
Instruct patient, family and care-givers in 
appropriate transfer techniques.  
B4  Establish or  To improve the patient's functional level by 
Upgrade Home instruction to the patient and responsible 
Program   individuals in exercise which may be used as an 
adjunct to PT programs.  
B5  Gait Training   Includes gait evaluation and ambulation training 
of a patient whose ability to walk has been 
impaired. Gait training is the selection and 
instruction in use of various assistive devices 
(orthotic appliances, crutches, walker, cane, etc.).  
     
B6  Pulmonary  Includes breathing exercises, postural drainage, 
Physical  etc., for patients with acute or severe pulmonary 
Therapy   dysfunction.  
B7  Ultra Sound   Mechanism to produce heat or micro-massage in 
deep tissues for conditions in which relief of pain, 
increase in circulation and increase in local 
metabolic activity are desirable.  
B8  Electro  Includes treatment for neuromuscular dysfunction 
Therapy   and pain through use of electrotherapeutic 
devices (electromuscular stimulation, 
Transcutaneous Electrical Nerve Stimulation 
(TENS), Functional Electrical Stimulation (FES), 
biofeedback, High Voltage Galvanic Stimulation 
(HVGS), etc.).  
B9  Prosthetic  Includes stump conditioning, (shrinking, shaping, 
Training   etc.), range of motion, muscle strengthening and 
gait training with or without the prosthesis and 
appropriate assistive devices.  
B10  Fabrication  Includes fabrication of temporary prostheses, 
Temporary  braces, splints, and slings.  
Devices  
B11  Muscle Re- Includes therapy designed to restore function due 
education   to illness, disease, or surgery affecting 
neuromuscular function.  
B12  Management  The complexity of necessary unskilled services 
and Evaluation  require skilled management by a qualified 
of a Patient  physical therapist to ensure that these services 
Care Plan   achieve their purpose, and to promote the 
beneficiary's recovery and medical safety.  
B13  Reserved    
B14  Reserved    
B15 Other (Spec.  Includes all PT services not identified above. 
Under Orders)  Specific therapy services are identified under 
physician's orders (Form CMS-485, Item 21). 
 
* Code which requires a more extensive descriptive narrative for physicians orders. 
 
C.  Speech Therapy (ST) 
 
These codes represent the services to be performed by the speech therapist. The following 
is a further explanation of each service. 
 
     
     
C1  Evaluation   Visit made to determine the type, severity 
and prognosis of a communication 
disorder, whether speech therapy is 
reasonable and necessary and to establish 
the goals, treatment plan, and estimated 
frequency and duration of treatment.  
C2  Voice Disorders  Procedures and treatment for patients with 
Treatments   an absence or impairment of voice caused 
by neurologic impairment, structural 
abnormality, or surgical procedures 
affecting the muscles of voice production.  
C3  Speech Articulation  Procedures and treatment for patients with 
Disorders Treatments   impaired intelligibility (clarity) of speech 
- usually referred to as anarthria or 
dysarthria and/or impaired ability to 
initiate, inhibit, and/or sequence speech 
sound muscle movements  usually 
referred to as apraxia/dyspraxia.  
C4  Dysphagia Treatments  Includes procedures designed to facilitate 
and restore a functional swallow.  
C5  Language Disorders  Includes procedures and treatment for 
Treatments   patients with receptive and/or expressive 
aphasia/dysphasia, impaired reading 
comprehension, written language 
expression, and/or arithmetical processes.  
C6  Aural Rehabilitation   Procedures and treatments designed for 
patients with communication problems 
related to impaired hearing acuity.  
C7  Reserved    
C8  Non-oral  Includes any procedures designed to 
Communications   establish a non-oral or augmentive 
communication system.  
C9* Other (Spec. Under  Speech therapy services not included 
Orders)  above. Specify service to be rendered 
under physician's orders (Form CMS-485, 
Item 21). 
 
* Code which requires a more extensive descriptive narrative for physicians orders. 
 
D  Occupational Therapy 
 
These codes represent the services to be rendered by the occupational therapist. The 
following is a further explanation of each service: 
 
     
     
D1   Evaluation   Visit made to determine occupational 
therapy needs of the patient at the home. 
Includes physical and psychosocial 
testings, establishment of plan of care, 
rehabilitation goals, and evaluating the 
home environment for accessibility and 
safety and recommending modifications.  
D2   Independent  Refers to the skills and performance of 
Living/Daily Living  physical cognitive and 
Skills (ADL  psychological/emotional self care, work, 
Training)   and play/leisure activities to a level of 
independence appropriate to age, life-
space, and disability.  
D3   Muscle Re-education  Includes therapy designed to restore 
function lost due to disease or surgical 
intervention.  
D4   Reserved    
D5   Perceptual Motor  Refers to enhancing skills necessary to 
Training   interpret sensory information so that the 
individual can interact normally with the 
environment. Training designed to 
enhance perceptual motor function 
usually involves activities, which 
stimulate visual and kinesthetic channels 
to increase awareness of the body and its 
movement.  
D6   Fine Motor  Refers to the skills and the performance 
Coordination   in fine motor and dexterity activities.  
D7   Neurodevelop-mental  Refers to enhancing the skills and the 
Treatment   performance of movement through 
eliciting and/or inhibiting stereotyped, 
patterned, and/or involuntary responses, 
which are coordinated at subcortical and 
cortical levels.  
D8   Sensory Treatment   Refers to enhancing the skills and 
performance in perceiving and 
differentiating external and internal 
stimuli such as tactile awareness, 
stereognosis, kinesthesia, proprioceptive 
awareness, ocular control, vestibular 
awareness, auditory awareness, gustatory 
awareness, and factory awareness 
necessary to increase function.  
     
D9   Orthotics Splinting   Refers to the provision of dynamic and 
static splints, braces, and slings for 
relieving pain, maintaining joint 
alignment, protecting joint integrity, 
improving function, and/or decreasing 
deformity.  
D10  Adaptive Equipment   Refers to the provision of special devices 
(Fabrication and  that increase independent functions.  
Training)  
D11* Other  Occupational therapy services not 
quantified above. 
 
* Code which requires a more extensive descriptive narrative for physicians orders. 
 
E.  Medical Social Services (MSS) 
 
These codes represent the services to be rendered by the medical social service worker. 
The following is a further explanation of each service: 
 
     
E1  Assessment of Social  Skilled assessment of social and 
and Emotional Factors  emotional factors related to the patient's 
illness, need for care, response to 
treatment and adjustment to care; 
followed by care plan development.  
E2  Counseling for Long- Assessment of patient's needs for long 
Range Planning and  term care including: Evaluation of home 
Decision making   and family situation; enabling 
patient/family to develop an in-home care 
system; exploring alternatives to in-home 
care; or arrangement for placement.  
E3  Community Resource  The promotion of community centered 
Planning   services(s) including education, advocacy, 
referral and linkage.  
E4*  Short Term Therapy   Goal oriented intervention directed toward 
management of terminal illness; 
reaction/adjustment to illness; 
strengthening family/support system; 
conflict resolution related to chronicity of 
illness.  
E5  Reserved    
E6* Other (Specify Under  Includes other medical social services 
Orders)  related to the patient's illness and need for 
care. Problem resolution associated with 
     
high risk indicators endangering patient's 
mental and physical health including: 
Abuse/neglect, inadequate food/medical 
supplies; and high suicide potential. The 
service to be performed must be written 
under doctor's orders (Form CMS-485, 
Item 21). 
 
* Code which requires a more extensive descriptive narrative for physicians orders. 
 
F.  Home Health Aide 
 
These codes represent the services to be rendered by the home health aide. Specific 
personal care services to be provided by the home health aide must be determined by a 
registered professional nurse. Services are given under the supervision of the nurse, and if 
appropriate, a physical, speech or occupational therapist. The following is a further 
explanation of each service: 
 
     
F1   Tub/Shower Bath   Assistance with tub or shower bathing.  
F2   Partial/Complete Bed  Bathing or assisting the patient with bed 
Bath   bath.  
F3   Reserved    
F4   Personal Care   Includes shaving of patient or 
shampooing the hair.  
F5   Reserved    
F6   Catheter Care   Care of catheter site and/or irrigations 
under nursing supervision.  
F7   Reserved    
F8   Assist with  Assisting the patient with ambulation as 
Ambulation   determined necessary by the nurse care 
plan.  
F9   Reserved    
F10  Exercises   Assisting the patient with exercises in 
accordance with the plan of care.  
F11  Prepare Meal   May be furnished by the aide during a 
visit for personal care.  
F12  Grocery Shop   May be furnished as an adjunct to a visit 
for personal care to meet the patient's 
nutritional needs in order to prevent or 
postpone the patient's institutionalization.  
     
F13  Wash Clothes   This service may be provided as it relates 
to the comfort and cleanliness of the 
patient and the immediate environment.  
F14  Housekeeping   Household services incidental to care and 
which do not substantially increase the 
time spent by the home health aide.  
F15* Other (Specify Under  Includes other home health aide services 
Orders)   in accordance with determination made 
by a registered professional nurse. 
Specified in Form CMS-485, Item 21. 
 
  Code which requires a more extensive descriptive narrative for physicians orders. 
   
Exhibit 31 - Form CMS-485, Home Health Certification and Plan of 
Care (Rev. 23, 03-18-02) 
 
View Form CMS-485 (PDF, 10 KB) 
Exhibit 32 - Harkin Grantee Winframe Database Access and Operation 
Instructions - (Rev. 32, 10-25-02) 
 
View the Harkin Grantee Winframe Database Access and Operation Instructions (PDF, 
298 KB)  
Exhibit 33 - Harkin Grantee Model Form -- (Rev. 32, 10-25-02) 
 
View the Harkin Grantee Model Form (PDF, 74.6 KB)  
 
HARKIN PROJECT FRAUD AND ABUSE COMPLAINT REFERRAL 
FORM 
 
 
DATE: 
 
From: (Your Name)___________________________  Organization: 
____________________ 
 
 
Address:_____________________  City:_________________ State:__________   
 
Zip:________   
 
 
     
Phone: (With Area Code)        Fax #      E-Mail (If 
Applicable) 
 
Beneficiary Name:           Medicare #:        Medicaid #: 
          
Date of Birth: 
 
 
Address:              Phone #: (With Area Code) 
 
 
City:            State:        Zip: 
 
 
Name of Complainant  (If Different From Beneficiary): 
 
 
Address:              Phone #: (With Area Code) 
 
 
City:            State:        Zip: 
 
Complaint Against: (Name of facility, provider, physician, lab, supplier, etc.)   
Claim # (If appropriate) 
 
 
 
Date(s) of Service: 
Business Address:          Phone: (With Area Code) 
 
                     Provider Number: 
City:            State:        Zip: 
 
 
Description of Complaint: 
Please describe your complaint.  If known, include procedure code and/or description of 
service, amounts billed, amount you paid, etc.  You may continue on the next page if you 
need more room.  If you feel you were billed for services or supplies that were not 
provided, continue on with the non-rendered service section below. 
 
 
 
 
 
 
     
 
 
 
 
Non-rendered Services Section: 
 
Did you see any provider that day? ______________ If yes, who? (Physicians Assistant, 
Nurse, Lab, X-ray Technician) 
 
Was the service(s) provided on another day? _______________ If yes, when? _________  
 
Have you ever seen the provider listed? ___________________ If yes, when? _________ 
 
Have you contacted the provider/supplier regarding this billing?  ______ Yes   _____ No 
 
If yes, to whom did you speak and what was the result of the conversation? 
 
I authorize ________________________________ and  (insert name of project)_ to 
discuss my complaint for the purpose of investigating possible fraud or abuse.  
 
I understand that, except for action already taken, I may revoke this authorization at any 
time.  I also understand that a photocopy of this authorization has the same effect as the 
original.  I further understand that the parties named above will not disclose this 
information to anyone else without my consent.  This authorization expires one (1) year 
from the date on which it is signed.  
 
________________________________          ________________ 
Signature                       Date 
 
If receiving a telephone complaint write telephone complaint on the signature line 
 
Important:  Please attach the appropriate Medicare and/or Medicaid Explanation of Benefits relating to this 
incident.  Also attach any other information you feel may be important to this complaint.   When completed 
mail to: (insert name of project) 
 
 
Exhibit 34  Reserved for Future Use 
(Rev. 548, Issued: 10-17-14; Effective Date: 11-18-14, Implementation Date: 11-18-14) 
 
Exhibit 34.2 - CERT Formats for Carrier and DMERC Standard 
Systems 
(Rev. 77, 05-28-04) 
 
File Formats Error! Bookmark not defined. 
 
     
Claims Universe File 
Claims Universe Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  1 
Contractor Type   X(1)  7  7  Spaces 
Universe Date   X(8)  8  15  Spaces 
 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number  
Validation:  Must be a valid CMS Contractor ID 
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Record Type 
Definition:  Code indicating type of record   
Validation:  N/A 
Remarks:  1 = Header record 
Requirement:  Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor  
Validation:  Must be B or D 
Remarks:  B = Part B 
D = DMERC 
Requirement:  Required 
 
Data Element: Universe Date 
Definition:  Date the universe of claims entered the standard system  
Validation:  Must be a valid date not equal to a Universe Date sent on any previous 
Claims Universe file 
Remarks:  Format is CCYYMMDD. May use standard system batch processing date 
Requirement:  Required 
      
Claims Universe File 
Claims Universe Claim Record  
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  2" 
Claim Control Number   X(15)  7  21  Spaces 
Beneficiary HICN   X(12)  22  33  Spaces 
Billing Provider  X(15)  34  48  Spaces 
Line Item Count  S9(2)   49  50  Zeroes 
Line Item group:         
  The following group of  
  Fields occurs from 1 to 52 
  Times (depending on Line 
  Item Count).   
 
                                                     From and Thru values relate to the 1st line item  
Performing Provider Number  X(15)  51   65  Spaces 
Performing Provider Specialty  X(2)  66  67  Spaces 
HCPCS Procedure Code   X(5)  68  72  Spaces 
DATA ELEMENT DETAIL 
 
Claim Header Fields 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number  
Validation:  Must be a valid CMS Contractor ID  
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Record Type 
Definition:  Code indicating type of record   
Validation:  N/A 
Remarks:  2 = claim record 
Requirement:  Required 
 
Data Element: Claim Control Number 
Definition:  Number assigned by the standard system to uniquely identify the claim  
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Beneficiary HICN 
Definition:  Beneficiarys Health Insurance Claim Number  
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Billing Provider Number 
Definition:  Number assigned by the standard system to identify the billing/pricing 
provider or supplier 
Validation:  NA 
Remarks:  Must be present if claim contains the same billing/pricing provider number 
on all 
      lines.  Otherwise move all zeroes to this field 
Requirement:  Required 
 
     
Data Element: Line Item Count 
Definition:  Number indicating number of service lines on the claim 
Validation:  Must be a number 01  52  
Remarks:  N/A 
Requirement:  Required 
 
Claim Line Item Fields  
 
Data Element: Performing Provider Number  
Definition:  Number assigned by the standard system to identify the provider who 
performed the service or the supplier who supplied the medical equipment  
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required  
 
Data Element: Performing Provider Specialty  
Definition:  Code indicating the primary specialty of the performing provider or supplier 
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required 
 
Data Element: HCPCS Procedure Code  
Definition:  The HCPCS/CPT-4 code that describes the service  
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required 
   
     
Claims Universe File 
Claims Universe Trailer Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  3 
Number of Claims   9(9)  7  15  Zeroes 
 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number  
Validation:  Must be a valid CMS Contractor ID  
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Record Type 
Definition:  Code indicating type of record   
Validation:  N/A 
Remarks:  3 = Trailer record 
Requirement:  Required 
 
Data Element: Number of Claims 
Definition:  Number of claim records on this file (Do not count header or trailer record.) 
Validation:  Must be equal to the number of claims records on the file 
Remarks:  N/A 
Requirement:  Required 
 
Sampled Claims Transaction File 
 
Field Name  Picture  From  Thru 
Contractor ID  X(5)  1  5 
Claim Control Number   X(15)  6  20 
Beneficiary HICN   X(12)  21  32 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number  
 
Data Element: Claim Control Number 
Definition:  Number assigned by the standard system to uniquely identify the claim  
 
Data Element: Beneficiary HICN 
Definition:  Beneficiarys Health Insurance Claim Number  
   
     
Sampled Claims Resolution File 
Sampled Claims Resolution Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  '1' 
Contractor Type   X(1)  7  7  Spaces 
File Date   X(8)  8  15  Spaces 
 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number  
Validation:  Must be a valid CMS Contractor ID  
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Record Type 
Definition:  Code indicating type of record   
Validation:  N/A 
Remarks:  1 = Header record 
Requirement:  Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor  
Validation:  Must be B or 'D 
Remarks:  B = Part B 
      D = DMERC 
Requirement:  Required 
 
Data Element: File Date 
Definition:  Date the Sampled Claims Resolution file was created  
Validation:  Must be a valid date not equal to a File Date sent on any previous Sampled 
Claims Resolution file 
Remarks:  Format is CCYYMMDD  
Requirement:  Required 
 
Sampled Claims Resolution File 
Sampled Claims Resolution Detail Record (one record per claim) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  2 
Claim Type  X(1)  7  7  Space 
Assignment Indicator  X(1)  8  8  Space 
Mode of Entry Indicator  X(1)  9  9  Space 
Original Claim Control Number  X(15)  10  24  Spaces 
Claim Control Number   X(15)  25  39  Spaces 
Beneficiary HICN   X(12)  40  51  Spaces 
Beneficiary Name  X(30)  52  81  Spaces 
Beneficiary Date Of Birth  X(8)  82  89  Spaces 
Billing Provider Number  X(15)  90  104  Spaces 
Referring Provider Number  X(15)  105  119  Spaces 
 
Paid Amount  9(7)v99  120  128  Zeroes 
Claim ANSI Reason Code 1  X(8)  129  136  Spaces 
     
Sampled Claims Resolution File 
Sampled Claims Resolution Detail Record (one record per claim) 
 
Field Name  Picture  From  Thru  Initialization 
Claim ANSI Reason Code 2  X(8)  137  144  Spaces 
Claim ANSI Reason Code 3  X(8)  145  152  Spaces 
Claim Entry Date  X(8)  153  160  Spaces 
Claim Adjudicated Date  X(8)  161  168   Spaces 
Line Item Count  9(2)  169  170  Zeroes 
Line Item group:         
   The following group of                  
   fields occurs from 1 to 52 times  
  (depending on Line Item Count). 
                                                     From and Thru values relate to the 1st line item  
Performing Provider Number  X(15)  171  185  Spaces 
Performing Provider Specialty  X(2)  186  187  Spaces 
HCPCS Procedure Code   X(5)  188  192  Spaces 
HCPCS Modifier 1   X(2)  193  194  Spaces 
HCPCS Modifier 2   X(2)  195  196  Spaces 
HCPCS Modifier 3  X(2)  197  198  Spaces 
HCPCS Modifier 4   X(2)  199  200  Spaces 
Number of Services  999v9  201  204  Zeroes 
Service From Date  X(8)  205  212  Spaces 
Service To Date  X(8)  213  220  Spaces 
Place of Service  X(2)  221  222  Spaces 
Type of Service  X(1)  223   223  Spaces 
Diagnosis Code  X(5)  224   228  Spaces 
CMN Control Number  X(15)  229   243  Spaces 
Submitted Charge  9(7)v99  244  252  Zeroes 
Medicare Initial Allowed Charge   9(7)v99   253  261  Zeroes 
ANSI Reason Code 1  X(8)  262   269  Spaces 
ANSI Reason Code 2  X(8)  270  277  Spaces 
ANSI Reason Code 3  X(8)  278  285  Spaces 
ANSI Reason Code 4  X(8)  286  293  Spaces 
ANSI Reason Code 5  X(8)  294  301  Spaces 
   
     
ANSI Reason Code 6  X(8)  302  309  Spaces 
ANSI Reason Code 7   X(8)  310  317  Spaces 
Manual Medical Review Indicator  X(1)  318  318  Space 
Resolution Code  X(5)  319  323  Spaces 
Final Allowed Charge              9(7)v99  324  332  Zeroes 
Filler              X(25)               333             357            
Spaces  
 
 
DATA ELEMENT DETAIL 
 
Claim Header Fields 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number  
Validation:  Must be a valid CMS Contractor ID  
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Record Type 
Definition:  Code indicating type of record   
Validation:  N/A 
Remarks:  2 = Claim record 
Requirement:  Required 
 
Data Element: Claim Type 
Definition:  Type of claim  
Validation:  Must be B or  D 
Remarks:  B = Part B 
      D = DMERC 
Requirement:  Required 
 
Data Element: Assignment Indicator 
Definition:  Code indicating whether claim is assigned or non-assigned 
Validation:  Must be A or N 
Remarks:  A = Assigned 
      N = Non-assigned 
Requirement:  Required 
 
Data Element: Mode of Entry Indicator 
Definition:  Code that indicates if the claim is paper or EMC  
Validation:  Must be E or P 
Remarks:  E = EMC 
      P = Paper 
Use the same criteria to determine EMC or paper as that used for workload reporting 
Requirement:  Required 
 
Data Element: Original Claim Control Number 
Definition:  Number assigned by the standard system to provide a crosswalk to pull all 
claims associated with the sample claim  
Validation:  N/A 
Remarks:  N/A 
Requirement: 
 
Data Element: Claim Control Number 
Definition:  Number assigned by the standard system to uniquely identify the claim  
Validation:  N/A 
Remarks:  N/A 
     
Requirement:  Required 
Data Element: Beneficiary HICN 
Definition:  Beneficiarys Health Insurance Claim Number  
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Beneficiary Name 
Definition:  Name of the beneficiary  
Validation:  N/A 
Remarks:  First, middle and last names must be strung together to form a formatted 
name (e.g., John E Doe) 
Requirement:  Required 
 
Data Element: Beneficiary Date of Birth 
Definition:  Date on which beneficiary was born. 
Validation:  Must be a valid date  
Remarks:  Month, day and year on which the beneficiary was born 
Requirement:  Required 
 
Data Element: Billing Provider Number 
Definition:  Number assigned by the standard system to identify the billing/pricing 
provider or supplier.  
Validation:  Must be present if claim contains the same billing/pricing provider number 
on all lines  
Remarks:  N/A 
Requirement: Required for all claims, assigned and non-assigned, containing the same 
billing/pricing provider on all lines  
 
Data Element: Referring Provider Number  
Definition:  Number assigned by the Standard System to identify the referring provider.  
Validation:  N/A 
Remarks:  Enter zeros if there is no referring provider. 
Requirement:  Required. 
 
Data Element: Paid Amount 
Definition:  Net amount paid after co-insurance and deductible.  Do not include interest 
you paid in the amount reported. 
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required. 
 
Data Element: Claim ANSI Reason Code 1  
Claim ANSI Reason Code 2 
Claim ANSI Reason Code 3 
Definition:  Codes showing the reason for any adjustments to this claim, such as denials 
or reductions of payment from the amount billed  
Validation:  Must be valid ANSI ASC claim adjustment codes and applicable group 
codes 
Remarks:  Format is GGRRRRRR where:  GG is the group code and RRRRRR is the 
adjustment reason code 
Requirement: ANSI Reason Code 1 must be present on all claims.  Codes 2 and 3 should 
be sent, if available. 
 
Data Element: Claim Entry Date 
Definition:  Date claim entered the standard claim processing system 
Validation:  Must be a valid date 
Remarks:  Format must be CCYYMMDD  
     
Requirement:  Required 
 
 
 
Data Element: Claim Adjudicated Date 
Definition:  Date claim completed adjudication 
Validation:  Must be a valid date.  Format must be CCYYMMDD  
Remarks:  This must represent the processed date that may be prior to the pay date if 
the claim is held on the payment floor after a payment decision has been 
made  
Requirement:  Required 
 
Data Element: Line Item Count 
Definition:  Number indicating number of service lines on the claim 
Validation:  Must be a number 01  52 
Remarks:  N/A 
Requirement:  Required 
 
Claim Line Item Fields  
 
Data Element: Performing Provider Number  
Definition:  Number assigned by the standard system to identify the provider who 
performed the service or the supplier who supplied the medical equipment  
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required  
 
Data Element: Performing Provider Specialty  
Definition:  Code indicating the primary specialty of the performing provider or supplier 
Validation:  N/A 
Remarks:   N/A 
Requirement:  Required 
 
Data Element: Referring Provider Number  
Definition:  Number assigned by the standard system to identify the referring provider  
Validation:  N/A 
Remarks:  Enter zeros if there is no referring provider 
Requirement:  Required 
 
Data Element: HCPCS Procedure Code  
Definition:  The HCPCS/CPT-4 code that describes the service  
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required 
 
Data Element: HCPCS Modifier 1 
      HCPCS Modifier 2 
      HCPCS Modifier 3 
      HCPCS Modifier 4 
Definition:  Codes identifying special circumstances related to the service  
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required if available 
 
Data Element: Number of Services  
Definition:  The number of service rendered in days or units 
Validation:  N/A  
     
Remarks:  The last position should contain the value to the right of the decimal in the 
number of services.  Put a zero in the last position for whole numbers.  
Requirement:  Required 
 
Data Element: Service From Date  
Definition:  The date the service was initiated  
Validation:  Must be a valid date less than or equal to Service To Date 
Remarks:  Format is CCYYMMDD 
Requirement:  Required 
Data Element: Service To Date  
Definition:  The date the service ended  
Validation:  Must be a valid date greater than or equal to Service From Date 
Remarks:  Format is CCYYMMDD 
Requirement:  Required 
 
Data Element: Place of Service  
Definition:  Code that identifies where the service was performed  
Validation:  N/A 
Remarks:  Must be a value in the range of 00  99 
Requirement:  Required 
 
Data Element: Type of Service 
Definition:  Code that classifies the service  
Validation:  The code must match a valid CWF type of service code 
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Diagnosis Code  
Definition:  Code identifying a diagnosed medical condition resulting in the line item 
service  
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required 
 
Data Element: CMN Control Number 
Definition:  Number assigned by the standard system to uniquely identify a Certificate 
of Medical Necessity  
Validation:  N/A 
Remarks:  Enter a zero if no number is assigned  
Requirement:  Required on DMERC claims     
 
Data Element: Submitted Charge 
Definition:  Actual charge submitted by the provider or supplier for the service or 
equipment  
Validation:  N/A 
Remarks:   N/A 
Requirement:  Required 
 
Data Element: Medicare Initial Allowed Charge 
Definition:  Amount  Medicare  allowed  for  the  service  or  equipment  before  any 
reduction or denial  
Validation:  N/A 
Remarks:  This  charge  is  the  lower  of  the  fee  schedule  or  billed  amount  (i.e., 
Submitted Charge), except for those services (e.g., ASC) that are always 
paid at the fee schedule amount even if it is higher than the Submitted 
Charge.  If there is no fee schedule amount, then insert the Submitted 
Charge. 
Requirement:  Required 
     
 
Data Element: ANSI Reason Code 1 
ANSI Reason Code 2 
      ANSI Reason Code 3 
      ANSI Reason Code 4 
      ANSI Reason Code 5 
      ANSI Reason Code 6 
  ANSI Reason Code 7 
Definition:  Codes showing the reason for any adjustments to this line, such as denials 
or reductions of payment from the amount billed  
Validation:  Must be valid ANSI ASC claim adjustment codes and applicable group 
codes 
Remarks:  Format is GGRRRRRR where:  GG is the group code and RRRRRR is the 
adjustment reason code 
 
Requirement: Requirement:  ANSI Reason Code 1 must be present on all claims with 
resolutions   of  'DENMR,  'DENMC'  ,'DEO,  'RTP,  'REDMR, 
'REDMC',  
      or 'REO,APPAM,DENAM,REDAM.  
 
Data Element: Manual Medical Review Indicator   
Definition:  Code  indicating  whether  or  not  the  service  received  complex  manual 
medical review.  Complex review goes beyond routine review.  It includes 
the request for, collection of, and evaluation of medical records or any other 
documentation in addition to the documentation on the claim, attached to 
the claim, or contained in the contractors history file.  The review must 
require  professional  medial  expertise  and  must  be  for  the  purpose  of 
preventing payments of non-covered or incorrectly coded services. That 
includes reviews for the purpose of determining if services were medically 
necessary.  Professionals must perform the review, i.e., at a minimum, a 
Licensed Practical Nurse must perform the review.  Review requiring use 
of the contractor's history file does not make the review a complex review. 
A review is not considered complex if a medical record is requested from a 
provider and not received. If sufficient documentation accompanies a claim 
to  allow  complex  review  to  be  done  without  requesting  additional 
documentation, count the review as complex.  For instance if all relative 
pages from the patient's medical record  are submitted with the claim, 
complex  MR  could  be  conducted  without  requesting  additional 
documentation.   
Validation:  Must be 'Y or N 
Remarks:  Set to 'Y if service was subjected to complex manual medical review, else 
N 
Requirement:  Required 
 
Data Element: Resolution Code   
Definition:  Code indicating how the contractor resolved the line.  
 
Automated Review (AM):  An automated review occurs when a claim/line 
item passes through the contractor's claims processing system or any adjunct 
system containing medical review edits. 
 
Routine Manual Review (MR):  Routine review uses human intervention, 
but only to the extent that the claim reviewer reviews a claim or any 
attachment submitted by the provider. It includes review that involves 
review of any of the contractor's internal documentation, such as claims 
history file or policy documentation.   It does not include review that 
involves review of medical records or other documentation requested from 
a provider. A review is considered routine if a medical record is requested 
     
from a provider and not received.  Include prior authorization reviews in 
this category. 
 
Complex Manual Review (MC):  Complex review goes beyond routine 
review.  It includes the request for, collection of, and evaluation of medical 
records or any other documentation in addition to the documentation on the 
claim, attached to the claim, or contained in the contractors history file.  
The review must require professional medial expertise and must be for the 
purpose  of  preventing  payments  of  non-covered  or  incorrectly  coded 
services.  Professionals must perform the review, i.e., at a minimum; a 
Licensed Practical Nurse must perform the review.  Review requiring use 
of the contractor's history file does not make the review a complex review. 
A review is not considered complex if a medical record is requested from a 
provider and not received. If sufficient documentation accompanies a claim 
to  allow  complex  review  to  be  done  without  requesting  additional 
documentation, the review is complex.  For instance if all relevant pages 
from the patient's medical record are submitted with the claim, complex MR 
could be conducted without requesting additional documentation.  
Validation:  Must be APP, APPMR, APPMC, , DENMR,  DENMC,  DEO, 
RTP, REDMR, REDMC or REO,APPAM,DENAM,REDAM.  
 
 
 
Remarks: 
      APP          = Approved as a valid submission 
      APPMR    = Approved after manual medical review routine 
APPMC    = Approved after manual medical review complex.  If this codes 
is  
                     selected, set the Manual Medial Review Indicator to 'Y.' 
DENMR  =  Denied  for  medical  review  reasons  or  for  insufficient 
documentation of medical necessity, manual medical review routine 
      DENMR   = Denied after manual medical review routine 
DENMC      =  Denied  for  medical  review  reasons  or  for  insufficient 
documentation 
                      medical necessity, manual medical review complex.  If this 
codes is 
                      selected, set the Manual Medial Review Indicator to 'Y.'  
      DEO        = Denied for non-medical reasons, other than denied as 
unprocessable.  
      RTP         = Denied as unprocessable (return/reject) 
REDMR    =  Reduced  for  medical  review  reasons  or  for  insufficient 
documentation  
                    of medical necessity, manual medical review routine 
REDMC      =  Reduced  for  medical  review  reasons  or  for  insufficient 
documentation of medical necessity, manual medical review 
complex.   If  this code  is selected, set the Manual Medial 
Review Indicator to 'Y.' 
REO         = Reduced for non-medical review reasons. 
APPAM    = Approved after automated medical review 
DENAM   = Denied after automated medical review 
REDAM   = Reduced after medical review 
Requirement:  Required. 
 
Data Element: Final Allowed Charge 
Definition:  Final Amount allowed for this service or equipment after any reduction or 
denial  
Validation:  N/A 
     
Remarks:  This represents the contractors value of the claim gross of co-pays and 
deductibles 
Requirement:  Required 
 
Data Element: Filler  
Definition:  Additional space TBD  
Validation:  N/A 
Remarks:  N/A 
Requirement:  None   
 
 
 
Sampled Claims Resolution File 
Sampled Claims Resolution Trailer Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  3 
Number of Claims   9(9)  7  15  Zeroes 
 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number  
Validation:  Must be a valid CMS Contractor ID  
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Record Type 
Definition:  Code indicating type of record   
Validation:  N/A 
Remarks:  3 = Trailer record 
Requirement:  Required 
 
Data Element: Number of Claims 
Definition:  Number of sampled claim resolution records on this file (Do not count 
header or trailer record.) 
Validation:  Must be equal to the number of sampled claims resolution records on the 
file 
Remarks:  N/A 
Requirement:  Required 
   
     
Provider Address File 
Provider Address Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  1 
Contractor Type   X(1)  7  7  Spaces 
File Date   X(8)  8  15  Spaces 
 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number  
Validation:  Must be a valid CMS Contractor ID  
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Record Type 
Definition:  Code indicating type of record   
Validation:  N/A 
Remarks:  1 = Header record 
Requirement:  Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor  
Validation:  Must be B or D 
Remarks:  B = Part B 
      D = DMERC 
Requirement:  Required 
 
Data Element: File Date 
Definition:  Date the Provider Address file was created  
Validation:  Must be a valid date not equal to a File Date sent on any previous Provider 
Address file 
Remarks:  Format is CCYYMMDD  
Requirement:  Required 
 
     
Provider Address File 
Provider Address Detail Record 
         
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  2 
Provider Number  X(15)  7  21  Spaces 
Provider Name  X(25)  22  46  Spaces 
Provider Address 1  X(25)  47  71  Spaces 
Provider Address 2  X(25)  72  96  Spaces 
Provider City  X(15)  97  111  Spaces 
Provider State Code  X(2)  112  113  Spaces 
Provider Zip Code  X(9)  114  122  Spaces 
Provider Phone Number  X(10)  123  132  Spaces 
Provider Fax Number        X(10)          133    142     Spaces 
Provider Type          X(1)           143    143     Spaces  
Filler             X(25)          144         168        Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number  
Validation:  Must be a valid CMS Contractor ID  
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Record Type 
Definition:  Code indicating type of record   
Validation:  N/A 
Remarks:  2 = Detail record 
Requirement:  Required 
 
Data Element: Provider Number 
Definition:  Number assigned by the standard system to identify the billing/pricing provider or 
supplier or referring provider 
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Provider Name 
Definition:  Providers name 
Validation:  N/A 
Remarks:  This is the name of the billing/pricing provider or referring provider must be 
formatted into a name for mailing (e.g. Roger A Smith M.D. or  Medical Associates, 
Inc.).  
Requirement:  Required 
 
Data Element: Provider Address 1 
Definition:  1st line of providers address 
Validation:  N/A 
Remarks:  This is the payee address1of the billing/pricing provider or referring provider 
Requirement:  Required  
 
Data Element: Provider Address 2 
Definition:  2nd line of providers address 
Validation:  N/A 
Remarks:  This is the address2 of the billing/pricing provider or referring provider  
Requirement:  Required if available  
 
Data Element: Provider City 
Definition:  Providers city name 
Validation:  N/A 
     
Remarks:  This is the city of the billing/pricing provider or referring provider  
Requirement:  Required  
 
Data Element: Provider State Code 
Definition:  Providers billing state code 
Validation:  Must be a valid state code 
Remarks:  This is the state of the billing/pricing provider or referring provider 
Requirement:  Required 
 
Data Element: Provider Zip Code 
Definition:  Providers billing zip code 
Validation:  Must be a valid postal zip code  
Remarks:  This is the zip code of the billing/pricing provider or referring provider.  Provide 9-
digit zip code if available, otherwise provide 5-digit zip code   
Requirement:  Required 
 
Data Element: Provider Phone Number 
Definition:  Providers telephone number 
Validation:  Must be a valid telephone number  
Remarks:  This is the phone number of the billing/pricing provider or referring provider  
Requirement:  None 
 
Data Element: Provider Fax Number 
Definition:  Providers fax number 
Validation:  Must be a valid fax number  
Remarks:   This is the fax number of the billing/pricing provider or referring provider  
Requirement:  None 
 
Data Element: Provider Type 
Definition:  1=billing/pricing provider 2= referring provider 
Validation:  Must be a valid provider type  
Remarks:  This field indicates whether the information provided on the record is for the 
billing/pricing provider or referring provider  
Requirement:  Required 
 
Data Element: Filler  
Definition:  Additional space TBD  
Validation:  N/A 
Remarks:  N/A 
Requirement: 
 
Provider Address File 
Provider Address Trailer Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  3 
Number of Records  9(9)  7  15  Zeroes 
 
 
 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number  
Validation:  Must be a valid CMS Contractor ID  
Remarks:  N/A 
Requirement:  Required 
 
Data Element: Record Type 
     
Definition:  Code indicating type of record   
Validation:  N/A 
Remarks:  3 = Trailer record 
Requirement:  Required 
 
Data Element: Number of Records 
Definition:  Number of provider address records on this file (do not count header or trailer 
record) 
Validation:  Must be equal to the number of provider address records on the file 
Remarks:  N/A 
Requirement:  Required 
 
 
Claims History Replica file 
Claims History Record (one record per claim) 
 
 
DATA ELEMENT DETAIL 
 
This format of this file will be identical to each individual standard systems claims history file.  
It should not include header or trailer records. 
 
Exhibit 34.6  CERT PSC Contractor Feedback Data Entry Screen Version 1.01 
(Rev. 77, 05-28-04) 
 
 
Figure 1:  CERT PSC Contractor Feedback Data Entry Screen 
 
Your failure to provide the requested documentation to the CERT PSC will result in a 
documentation error for that line of service and you may not re-submit the line to the CERT 
Contractor Resolution Process (CCRP), even where your staff have previously conducted 
routine or complex MR. 
 
The CMS will conduct a routine quality assurance review of the CERT program including 
review of claims with error and non-error findings. 
 
     
The CERT PSC will provide your CERT PSC Contractor Feedback Data Entry Screen to 
CMS and will also maintain a tracking database of all such reports you submitted to CMS to 
include final disposition of error findings submitted to the CCRP.  Do not provide that 
information to other entities; the CMS will handle all requests for copies of those reports. 
 
Exhibit 34.7 - Data Items Included on CERT Reports 
(Rev. 77, 05-28-04) 
 
The CMS Central Office Clinical Panel (COCP) will receive the following for each line 
submitted to the CCRP: 
 
Relevant information from the medical record for the disagreed upon line of service, 
Explanations from the CERT PSC and the AC of their decisions, and 
Specific references to included documentation that the AC or the CERT PSC believes 
supports their decision. 
 
The COCP will make a decision based upon all information presented to them. 
To insure that regional offices (ROs) have an opportunity to be involved in the CCRP, the 
COCP will invite the participation of RO clinicians in the process. 
 
The COCP at a minimum will consist of four individuals.  There will be physician 
representation from the Center for Medicare Management (CMM), Office of Clinical 
Standards & Quality (OCSQ), and Program Integrity Group (PIG).  There will be at least 
one registered nurse on this panel.  The COCP will request the participation of consortia 
staff; requests will be made at least one month before participation is expected.  The panel 
may request the assistance of complex medical review experts, coding experts, or clinical 
specialists.  A list of all participants must accompany the final report from the panel. 
 
Members of panels will review the file presented without opportunity for the CERT PSC or 
you to submit additional material.  You may make no further appeal. 
 
The CMS will provide final results from the COCP reviews to you in the CERT Quarterly 
Error Reconciliation Report (see attachment 5 for the report format); CMS will include in 
this report only those lines the COCP has confirmed to be in error after the COCP has 
completed all review of lines you submitted to the CCRP for that quarter. 
 
You will collect overpayments on all lines paid in error included in the Error Report except 
for errors submitted to the CCRP. You will also collect overpayments on all lines in error 
included in the CERT Quarterly Error Reconciliation Report.  You will pay to the billing 
providers amounts that you have denied in error and the CERT PSC has identified as such. 
The CMS does not require collection or payment for errors in coding that do not affect the 
amount originally paid, e.g., a line with an incorrect code is paid, but the corrected code 
(determined after CERT review) is reimbursable at the same amount as the code in error.  
 
You should send all reports to: 
 
  AdvanceMed 
  1530 E. Parham Road 
  Richmond, Va. 23228. 
     
 
The CERT PSC will send reports to the CERT point of contact you identified. 
 
On an annual basis, the COCP will conduct random reviews of the decisions on requests 
submitted to the CCRP.  The QA findings shall be sent to the CERT PSC, AC, and applicable 
parties (i.e., RO or CO). 
 
Exhibit 35  Memorandum of Understanding (MOU) with Law Enforcement  
 
DEPARTMENT OF JUSTICE ACCESS TO  
MEDICARE CONTRACTOR INFORMATION 
 
Combating Medicare fraud is a goal shared by the Department of Justice (DOJ), Department of 
Health and Human Services Office of the Inspector General (OIG), and the Health Care 
Financing (HCFA). Investigating and prosecuting such cases typically requires access to 
information and documents from Medicare contractors. To ensure that law enforcements need 
for this information is met consistent with Medicare contractors other responsibilities, DOJ, 
OIG, and HCFA agree to the following procedures: 
 
1.  DOJ can request in writing information and documents related to an ongoing civil or 
criminal health care fraud investigation or prosecution directly from a Medicare 
contractor. DOJ includes personnel at the Federal Bureau of Investigation (FBI), 
United States Attorneys Offices, and the Department of Justice in Washington, D.C., 
including but not limited to the Criminal Division and Civil Division. 
 
2.  When DOJ requests information from a Medicare contractor, it must notify the 
Regional OIG in writing. 
 
OIG approval is not necessary for DOJ requests for information from a Medicare 
contractor. OIG notification is intended to prevent duplication in investigative efforts. 
 
3.  HCFA approval is not necessary before a Medicare contractor can provide information 
requested to DOJ. 
 
4.  It is presumed that a Medicare contractor will furnish DOJ officials with information 
and documents related to a civil or criminal health care fraud investigation or 
prosecution in a timely fashion. However, if a Medicare contractor objects to the 
request on the basis that it is unduly burdensome in terms of the volume of 
information requested, the timing of the request, or the format in which DOJ seeks the 
information, the Medicare contractor may take the following steps: 
 
a.  Contact the requesting DOJ official to explain the basis of the objection. All 
parties agree to make good faith efforts to reach a resolution that accommodates 
DOJs legitimate law enforcement needs and the Medicare contractors budgetary 
constraints or other needs. 
 
Legitimate requests include but are not limited to requests for the following 
documents: 
 
     
(1)  information contained on claim forms and other records maintained on 
individual providers or suppliers; 
 
(2)  billing procedure updates and other Medicare publications furnished to 
providers or suppliers; 
 
(3)  contractor correspondence to and from providers/suppliers; 
 
(4)  billing history of beneficiaries; 
 
(5)  analysis performed by Fraud and Abuse Units; 
 
(6)  data analysis routinely done by Medicare contractors such as utilization 
reviews. 
 
DOJ recognizes that general data analysis is typically the prerogative of the 
Medicare contractor and HCFA and, therefore, agrees to limit requests for data 
analysis not otherwise performed by the Medicare contractor. HCFA recognizes 
that OIG and DOJ may have legitimate law enforcement needs for data analysis 
in ongoing investigations and proceedings. Where DOJ requests data analysis not 
otherwise performed by the contractor, DOJ should discuss the request with the 
Medicare contractor to explain the need for such analysis and to determine 
whether there is an alternative format for a contractor to provide the information. 
 
b.  Where the FBI has sought the information, the FBI may involve in the resolution 
a representative of the United States Attorneys Office, DOJs Criminal Division 
or Civil Division. 
 
c.  If the Medicare contractor and the requesting DOJ official cannot reach an 
accommodation, then they may seek the intervention of HCFAs Associate 
Regional Administrator. It is anticipated that such an appeal will be a rare 
occurrence prevented by reasonable requests and timely and comprehensive 
responses. 
 
5.  Periodic meetings between DOJ, OIG, HCFA regional officials, and the Medicare 
contractors should be held at the local levels. Similar meetings between DOJ, OIG, 
and HCFA should be held at the national levels. Such meetings offer an opportunity to 
discuss trends in fraudulent practices; to devise possible solutions to stopping ongoing 
fraud; to report the status of DOJ health care fraud casesconsistent with DOJs 
enforcement needs and limitations on permissible disclosure of such information; to 
resolve problems, if any, concerning requests for information; and generally, to foster 
cooperation among law enforcement, HCFA, and Medicare contractors. 
 
6.  DOJ, OIG, and HCFA agree to conduct training to familiarize their respective 
personnel on the activities and needs of the others. 
 
7.  DOJ will handle the information and documents obtained from Medicare contractors 
consistent with existing statutory and regulatory provisions protecting confidentiality 
of patient records including, but not limited to, the Privacy Act of 1974. 
     
 
8.  Contractors requiring further instructions or clarification regarding any aspect of this 
policy, including the application of any statute or regulation, may contact the 
appropriate Associate Regional Administrator. 
 
This policy will be revisited six months from the date of its adoption. 
 
 
______________/s/_____________  ___________________/s/____ 
GERALD M. STERN       JUNE GIBBS BROWN 
Special Counsel for Health Care Fraud  Inspector General 
Department of Justice       Department of Health and Human Services 
 
 
 
______________/s/_____________ 
BRUCE VLADECK 
Administrator 
Health Care Financing Administration 
 
 
 
______________4/29/94_________ 
DATE 
 
 
36 - Overview of the CERT Process 
(Rev. 726, Issued: 06-16-17, Effective: 10-01-17, Implementation: 01-02-18 - For VMS and 
MCS for Business Requirements 11 through 22 and 22.1; 10-02-17 - For FISS) 
 
The CERT process begins at the MAC processing site where claims that have entered the 
standard claims processing system on a given day are extracted to create a Claims Universe File. 
This file is transmitted each day to the CERT Operations Center, where it is routed through a 
random sampling process. Claims that are selected as part of the sample are downloaded to the 
Sampled Claims Database. This database holds all sampled claims from all MACs. Periodically, 
sampled claim key data are extracted from the Sampled Claims Database to create a Sampled 
Claims Transaction File. This file is transmitted back to the MAC and matched to the MACs 
claims history and provider files. A Sampled Claims Resolution File, a Claims History Replica 
File, and a Provider Address file are created automatically by the MAC and transmitted to the 
CERT Operations Center. They are used to update the Sampled Claims database with claim 
resolutions and provider addresses; the Claims History Replica records are added to a database 
for future analysis. 
 
Software applications at the CERT Operations Center are used to review, track, and report on the 
sampled claims. Periodically, the CERT contractor requests the MAC to provide information 
supporting decisions on denied/reduced claims or claim line items and claims that have been 
subject to their medical review processes. The CERT contractor also sends reports identifying 
incorrect claim payment to the appropriate MAC for follow-up. MACs then report on their 
     
agreement and disagreement with CERT decisions, status of overpayment collections, and status 
of claims that go through the appeals process. 
 
Exhibit 36.1 - CERT Formats for A/B MAC (A) MACS and Shared Systems 
(Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
Claims Universe File 
Claims Universe Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  1 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Universe Date  X(8)  9  16  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number 
Validation:  Must be a valid CMS contractor ID 
Remarks:  N/A 
Requirement:   Required 
NOTE:   For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single  
processing environment, the Contractor ID will reflect the roll-up Contractor 
ID specified by CMS 
 
Data Element: Record Type 
Definition:    Code indicating type of record  
Validation:  N/A 
Remarks:  1 = Header 
record Requirement:  Required 
 
Data Element: Record Version Code 
Definition:   The code indicating the record version of the Claim Universe file 
Validation:  Claim Universe files prior to 10/1/2007 did not contain this field. 
Codes: 
B = Record Format as of 10/1/2007  
C = Record Format as of 10/1/2017 
Remarks:    N/A  
Requirement: Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor included in the file 
Validation:  Must be A or R 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
Remarks:  A = A/B MAC (A) only 
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH) 
Requirement: Required 
 
Data Element: Universe Date 
     
Definition:  Date the universe of claims entered the shared system 
Validation:  Must be a valid date not equal to a universe date sent on any previous claims 
universe file 
Remarks:  Format is CCYYMMDD. May use shared system batch processing date; 
however, the Universe Date must not equal the universe date on any previous 
claims universe file. 
Requirement: Required 
 
Claims Universe File 
Claims Universe Claim Record 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  2 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Internal Control Number  X(23)  9  31  Spaces 
Beneficiary HICN  X(12)  32  43  Spaces 
Billing Provider Number  X(9)  44  52  Spaces 
Billing Provider NPI  X(10)  53  62  Spaces 
Type of Bill  X(3)  63  65  Spaces 
Claim From Date  X (8)  66  73  Spaces 
Claim Through Date  X (8)  74  81  Spaces 
Condition Code 1  X (2)  82  83  Spaces 
Condition Code 2  X (2)  84  85  Spaces 
Condition Code 3  X (2)  86  87  Spaces 
Condition Code 4  X (2)  88  89  Spaces 
Condition Code 5  X (2)  90  91  Spaces 
Condition Code 6  X (2)  92  93  Spaces 
Condition Code 7  X (2)  94  95  Spaces 
Condition Code 8  X (2)  96  97  Spaces 
Condition Code 9  X (2)  98  99  Spaces 
Condition Code 10  X (2)  100  101  Spaces 
Condition Code 11  X (2)  102  103  Spaces 
Condition Code 12  X (2)  104  105  Spaces 
Condition Code 13  X (2)  106  107  Spaces 
Condition Code 14  X (2)  108  109  Spaces 
Condition Code 15  X (2)  110  111  Spaces 
Condition Code 16  X (2)  112  113  Spaces 
Condition Code 17  X (2)  114  115  Spaces 
Condition Code 18  X (2)  116  117  Spaces 
Condition Code 19  X (2)  118  119  Spaces 
Condition Code 20  X (2)  120  121  Spaces 
Condition Code 21  X (2)  122  123  Spaces 
Condition Code 22  X (2)  124  125  Spaces 
Condition Code 23  X (2)  126  127  Spaces 
Claim Demonstration Number  X(2)  128  129  Spaces 
PPS Indicator Code  X(1)  130  130  Spaces 
Claim State  X(2)  131  132  Spaces 
Beneficiary State  X(2)  133  134  Spaces 
Claim Total Charge Amount  9(8)V99  135  144  Zeroes 
Beneficiary MBI  X(11)  145  155  Spaces 
Hicn/MBI indicator  X(1)  156  156  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
Filler  X(2)  157  158  Spaces 
Revenue Code Count  9(3)  159  161  Zero 
Claims Universe File 
Claims Universe Revenue Code Group (Claim Line Items) 
*The following group of fields occurs from 1 to 450 times (depending on Revenue Code 
Count) 
 
*From and Thru values relate to the 1st line item 
 
Field Name  Picture  From  Thru  Initialization   
Revenue Center Code  X(4)  162  165  Spaces   
HCPCS  X(5)  166  170  Spaces   
 
Revenue Center Total Charge  9(8)V99  171  180  Zeroes 
 
DATA ELEMENT DETAIL 
 
Claim (Header) Fields 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number 
Validation:  Must be a valid CMS contractor ID 
Remarks:  N/A 
Requirement: Required 
NOTE:  For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor 
ID specified by CMS 
 
Data Element: Record Type 
Definition:  Code indicating type of record 
Validation:  N/A 
Remarks:  2 = claim 
record Requirement:  
Required 
 
Data Element: Record Version Code 
Definition:  The code indicating the record version of the Claim Universe file  
Validation:  Claim Universe files prior to 10/1/2007 did not contain this field. 
Codes: 
B = Record Format as of 
10/1/2007 C = Record Format as 
of 10/1/2017 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor included in the file 
Validation:  Must be A or R. 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
 
Data Element: Internal Control Number 
     
Definition:  Number assigned by the shared system to uniquely identify the claim 
Validation:  N/A 
Remarks:  Do not include hyphens or spaces 
Requirement: Required 
 
Data Element: Beneficiary HICN 
Definition:  Beneficiarys Health Insurance Claim Number 
Validation:  N/A 
Remarks:  Do not include hyphens or spaces 
Requirement:   Required 
 
Data Element:   Billing Provider Number 
Definition:  First nine characters of number assigned by Medicare to identify the 
billing/pricing provider or supplier. 
Validation:  N/A  
Remarks:  N/A  
Requirement: Required 
 
Data Element:   Billing Provider NPI 
Definition:  NPI assigned to the Billing Provider. 
Validation:  N/A 
Remarks:  N/A. 
Requirement: Required by May 23, 2007 for claims using HIPAA standard Transactions 
 
Data Element: Type of Bill 
Definition:  Three-digit alphanumeric code gives three specific pieces of information. The 
first digit identifies the type of facility. The second classifies the type of care. 
The third indicates the sequence of this bill in this particular episode of care. 
It is referred to as frequency code. 
Validation:  Must be a valid code as listed in Pub 100-4, Medicare Claims  
  Processing Manual, Chapter 25, Completing and Processing CMS-1450 Data 
Set. 
Remarks:   N/A  
Requirement: Required 
 
Data Element: Claim from Date 
Definition:  The first day on the billing statement covering services rendered to the 
beneficiary. 
Validation:  Must be a valid date 
Remarks:  Format is CCYYMMDD 
Requirement:   Required 
 
Data Element:   Claim through Date 
Definition:  The last day on the billing statement covering services rendered to the 
beneficiary. 
Validation:  Must be a valid date 
Remarks:  Format is CCYYMMDD 
Requirement:   Required 
 
Data Element:  Condition Code  1 
Condition Code  2 
Condition Code  3 
Condition Code  4 
Condition Code  5 
Condition Code  6 
Condition Code  7 
     
Condition Code  8 
Condition Code  9 
Condition Code 10 
Condition Code 11 
Condition Code 12 
Condition Code 13 
Condition Code 14 
Condition Code 15 
Condition Code 16 
Condition Code 17 
Condition Code 18 
Condition Code 19 
Condition Code 20 
Condition Code 21 
Condition Code 22 
Condition Code 23 
 
Definition:  The code that indicates a condition relating to an institutional 
claim that may affect payer processing. 
Validation:  Must be a valid code as defined in the Claims Processing Manual (Pub. 100-4) 
chapter 25 (Completing and Processing CMS-1450 Data Set). 
Remarks:  N/A 
Requirement:   Required if claim has a condition code 
 
Data Element: Claim Demonstration Identification Number 
Definition:  The number assigned to identify a demonstration Project. This field is also 
used to denote special processing (a.k.a. Special Processing Number, SPN). 
Validation:  Must be a Valid Demo ID.  
Remarks:  N/A 
Requirement:   Required when available on claim 
 
Data Element: PPS Indicator Code alias Claim PPS Indicator Code 
Definition:  The code indicating whether (1) the claim is Prospective Payment System 
(PPS), (2) Unknown or (0) not PPS. 
Validation:  0 = Not PPS 
1 = PPS 
2 = Unknown 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Claim State 
Definition:  2 character abbreviation identifying the state in which the service is furnished  
Validation:  Must be a valid 2 digit state abbreviation as defined by the United States 
Postal Service (USPS) or blank. 
Remarks:  N/A 
Requirement:   Required if on claim record 
 
Data Element: Beneficiary State 
Definition:  2 character abbreviation designating the state in which the beneficiary 
resides.  
Validation:  Must be a valid 2 digit state abbreviation as defined by the United States 
Postal Service (USPS) or blank. 
Remarks:  N/A 
Requirement:   Required if on claim record 
 
Data Element: Claim Total Charge Amount 
     
Definition:  The total charges for all services included on the institutional claim.  
Validation:  N/A 
Remarks:  This field should contain the same amount as revenue center code 0001/total 
charges. 
Requirement:   Required 
 
Data Element: Beneficiary MBI 
Definition:  Beneficiarys Medicare Beneficiary Identifier 
Validation:  Comply with CMS Standards 
  11-character, fixed length alpha-numeric string 
  Different, visibly distinguishable from HICN/RRB numbers 
  Contain no more than 2 consecutive numbers 
  Contain no more than 2 consecutive alphabetic characters 
  Must limit the possibility of letters being interpreted as numbers (i.e., 
alphabetic characters [A...Z]; excluding S, L, O, I, B, Z) 
  Must not contain lowercase letters 
  Must not contain any special characters  
 
Remarks:  Do not include hyphens or spaces  
Requirement:  Required, when available 
 
Data Element: HICN/MBI Indicator 
Definition:  Indicator that identifies if the provider submitted the claim with a HICN or MBI 
Validation:  M = MBI submitted on the claim 
H = HICN submitted on the claim 
Remarks:  N/A 
Requirement: 
  Required 
 
Data Element: Revenue Code Count 
Definition:  Number indicating number of revenue code lines on the claim. Include line 1 
in the count. 
Validation:  Must be a number 01  450  
Remarks:  N/A 
Requirement: 
  Required  
 
Claim Line Item Fields 
 
Data Element: Revenue Code 
Definition:  Code assigned to each cost center for which a charge is billed. 
Validation:  Must be a valid National Uniform Billing Committee (NUBC) approved code. 
Remarks:  Include an entry for revenue code 0001. 
Requirement:   Required 
 
Data Element: HCPCS Procedure Code or HIPPS Code 
Definition:  The HCPCS/CPT-4 code that describes the service or Health Insurance PPS 
(HIPPS) code. 
Validation:  Must be a valid HCPCS/CPT-4 code. 
Remarks:  Healthcare Common Procedure Coding System (HCPCS) is a collection of 
codes that represent procedures, supplies, products and services which may 
be provided to Medicare beneficiaries and to individuals enrolled in private 
health insurance programs. 
 
     
When revenue center code = '0022' (SNF PPS), '0023' (HH PPS), or '0024' 
(IRF PPS); this field contains the Health Insurance PPS (HIPPS) code. 
 
The HIPPS code for SNF PPS contains the rate code/assessment type that 
identifies RUG-III group the beneficiary was classified into as of the RAI MDS 
assessment reference date and (2) the type of assessment for payment 
purposes. 
 
The HIPPS code for Home Health PPS identifies (1) the three case-mix 
dimensions of the HHRG system, clinical, functional and utilization, from 
which a beneficiary is assigned to one of the 80 HHRG categories and (2) it 
identifies whether or not the elements of the code were computed or derived. 
The HHRGs, represented by the HIPPS coding, will be the basis of payment 
for each episode. 
 
The HIPPS code (CMG Code) for IRF PPS identifies the clinical characteristics 
of the beneficiary. The HIPPS rate/CMG code (AXXYY - DXXYY) must contain 
five digits. The first position of the code is an A, B, C, or 'D'.  The HIPPS code 
beginning with an 'A' in front of the CMG is defined as without co-morbidity. 
The 'B' in front of the CMG is defined as with co-morbidity for Tier 1. The 'C' is 
defined as co-morbidity for Tier 2 and 'D' is defined as co-morbidity for Tier 3. 
The 'XX' in the HIPPS rate code is the Rehabilitation Impairment Code (RIC). 
The 'YY' is the sequential number system within the RIC. 
 
Requirement:   Required if present on bill 
 
Data Element: Revenue Center Total Charge 
 
Definition:  The total charges (covered and non-covered) for all accommodations and 
services (related to the revenue code) for a billing period before reduction for 
the deductible and coinsurance amounts and before an adjustment for the 
cost of services provided 
 
Validation:  N/A 
Remarks:  N/A 
Requirement: 
  Required 
 
Claims Universe File 
Claims Universe Trailer Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  3 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Number of Claims  9(9)  9  17  Zeroes 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number 
Validation:  Must be a valid CMS contractor ID 
Remarks:  N/A 
Requirement:   Required 
     
NOTE:  For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor 
ID specified by CMS. 
 
Data Element: Record Type 
Definition:  Code indicating type of record 
Validation:  N/A 
Remarks:  3=Trailer Record 
Requirement:   Required 
 
Data Element: Record Version Code 
Definition:  The code indicating the record version of the Claim Universe file  
Validation:  Claim Universe files prior to 10/1/2007 did not contain this field. 
Codes:   B = Record Format as of 10/1/2007  
C = Record Format as of 10/1/2017 
Remarks:  N/A  
Requirement: 
  Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor included in the file. 
Validation:  Must be A or R 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type 
should be R. 
All others will be contractor type A. 
Remarks:   A = A/B MAC (A) only. 
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH). 
Requirement:   Required 
 
Data Element: Number of Claims 
Definition:   Number of claim records on this file 
Validation:  Must be equal to the number of claim records on the file. 
Remarks:  Do not count header or trailer records 
Requirement:    Required 
 
Claims Transaction File 
Claims Transaction Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  1 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Transaction Date  X(8)  9  16  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:   Contractors CMS assigned number.  
Validation:   Must be a valid CMS contractor ID.  
Remarks:   N/A 
Requirement:   Required 
     
NOTE:    For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor ID 
specified by CMS. 
 
Data Element: Record Type 
Definition:  Code indicating type of record 
Validation:  N/A 
Remarks:  1 = Header record 
Requirement:   Required 
 
Data Element: Record Version Code 
Definition:  The code indicating the record version of the Claim Transaction file.  
Validation:  Claim Transaction files prior to 10/1/2007 did not contain this field. 
Codes:   
B = Record Format as of 10/1/2007 
Remarks:  N/A 
Requirement: 
Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor included in the file  
Validation:  Must be A or R 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
 
Remarks:  A = A/B MAC (A) only 
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)  
Requirement:   Required 
 
Data Element: Transaction Date 
Definition:  Date the Transaction file was created 
Validation:  Must be a valid date not equal to a Transaction date sent on any previous 
claims Transaction file. 
Remarks:  Format is CCYYMMDD. May use shared system batch processing date.  
Requirement:   Required 
 
Sampled Claims Transaction File 
Sampled Claims Transaction File Detail Record 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  2 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Claim Control Number  X(23)  9  31  Spaces 
Beneficiary HICN  X(12)  32  43  Spaces 
 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:   Contractors CMS assigned number  
Validation:   Must be a valid CMS contractor ID  
     
Remarks:   N/A 
Requirement:   Required 
NOTE:  For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor 
ID specified by CMS. 
 
Data Element: Record Type 
Definition:  Code indicating type of record  
Validation:  N/A 
Remarks:  2 = claim record 
Requirement:   Required 
 
Data Element: Record Version Code 
Definition:  The code indicating the record version of the Claim Universe file  
Validation:  Claim Universe files prior to 10/1/2007 did not contain this field. 
Codes: 
B = Record Format as of 10/1/2007 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor included in the file 
Validation:  Must be A or R 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
  Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
 
Data Element: Claim Control Number 
Definition:  Number assigned by the shared system to uniquely identify the claim  
Validation:  N/A 
Remarks:  Reflects the Claim Control Number selected from the Claim Universe file in the 
sampling process. 
Requirement: Required 
 
Data Element: Beneficiary HICN 
Definition:  Beneficiarys Health Insurance Claim Number  
Validation:  N/A 
Remarks:  Reflects the Beneficiary HICN on the claim record selected from the Claim 
Universe file in the sampling process. 
Requirement:   Required  
 
Claims Transaction File 
Claims Transaction Trailer Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  3 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Number of Claims  9(9)  9  17  Zeroes 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
     
Definition:  Contractors CMS assigned number 
 
Validation:  Must be a valid CMS contractor ID 
Remarks:  N/A 
Requirement:   Required 
NOTE:  For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor 
ID specified by CMS. 
 
Data Element: Record Type 
Definition:  Code indicating type of record 
Validation:  N/A 
Remarks:  1 = Header record  
Requirement: 
  Required 
 
Data Element: Record Version Code 
Definition:  The code indicating the record version of the Claim Universe file 
Validation:  Claim Universe files prior to 10/1/2007 did not contain this field. 
Codes: 
B = Record Format as of 10/1/2007 
Remarks:  N/A 
Requirement: 
Required 
 
Data Element:   Contractor Type 
Definition:  Type of Medicare Contractor included in the file 
Validation:  Must be A or R. 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
Remarks:  A = A/B MAC (A) only 
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)  
Requirement:   Required 
 
Data Element: Number of Claims 
Definition:  Number of claim records on this file 
Validation:  Must be equal to the number of claim records on the file  
Remarks:  Do not count header or trailer records 
Requirement:   Required 
 
Claims Resolution File 
Claims Resolution Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  1 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Resolution Date  X(8)  9  16  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
     
Definition:  Contractors CMS assigned number 
Validation:  Must be a valid CMS contractor ID 
Remarks:  N/A 
Requirement:   Required 
NOTE:  For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor 
ID specified by CMS 
 
Data Element: Record Type 
Definition:  Code indicating type of record 
Validation:  N/A 
Remarks:  1 = Header record 
Requirement:   Required 
 
Data Element: Record Version Code 
Definition:  The code indicating the record version of the Claim Resolution file  
Validation:  Claim Resolution files prior to 10/1/2007 did not contain this field. 
Codes: 
B = Record Format as of 10/1/2007  
C = Record Format as of 1/1/2010  
D = Record Format as of 10/1/2012  
E = Record Format as of 7/1/2016  
F = Record Format as of 10/1/2017 
Remarks:  N/A 
Requirement:   Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor included in the file  
Validation:  Must be A or R 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
Remarks:  A = A/B MAC (A) only 
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)  
Requirement: Required 
 
Data Element: Resolution Date 
Definition:  Date the Resolution Record was created. 
Validation:  Must be a valid date not equal to a Resolution date sent on any previous 
claims Resolution file 
Remarks:  Format is CCYYMMDD. May use shared system batch processing date  
Requirement:   Required 
 
Sampled Claims Resolution File 
Sampled Claims Resolution Claim Detailed Record 
 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  2 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Record Number  9(1)  9  9  Zero 
     
Field Name  Picture  From  Thru  Initialization 
Mode of Entry Indicator  X(1)  10  10  Space 
Original Claim Control Number  X(23)  11  33  Spaces 
Internal Control Number  X(23)  34  56  Spaces 
Beneficiary HICN  X(12)  57  68  Spaces 
Beneficiary Last Name  X(60)  69  128  Spaces 
Beneficiary First Name  X(35)  129  163  Spaces 
Beneficiary Middle Initial  X(1)  164  164  Spaces 
Beneficiary Date of Birth  X(8)  165  172  Spaces 
Beneficiary Gender  X(1)  173  173  Spaces 
Billing Provider Number  X(9)  174  182  Spaces 
Attending Physician UPIN  X(6)  183  188  Spaces 
Claim Paid Amount  S9(8)V99  189  198  Zeroes 
Claim ANSI Reason Code 1  X(8)  199  206  Spaces 
Claim ANSI Reason Code 2  X(8)  207  214  Spaces 
Claim ANSI Reason Code 3  X(8)  215  222  Spaces 
Claim ANSI Reason Code 4  X(8)  223  230  Spaces 
Claim ANSI Reason Code 5  X(8)  231  238  Spaces 
Claim ANSI Reason Code 6  X(8)  239  246  Spaces 
Claim ANSI Reason Code 7  X(8)  247  254  Spaces 
Statement covers From Date  X(8)  255  262  Spaces 
Statement covers Thru Date  X(8)  263  270  Spaces 
Claim Entry Date  X(8)  271  278  Spaces 
Claim Adjudicated Date  X(8)  279  286  Spaces 
Condition Code 1  X(3)  287  289  Spaces 
Condition Code 2  X(3)  290  292  Spaces 
Condition Code 3  X(3)  293  295  Spaces 
Condition Code 4  X(3)  296  298  Spaces 
Condition Code 5  X(3)  299  301  Spaces 
Condition Code 6  X(3)  302  304  Spaces 
Condition Code 7  X(3)  305  307  Spaces 
Condition Code 8  X(3)  308  310  Spaces 
Condition Code 9  X(3)  311  313  Spaces 
Condition Code 10  X(3)  314  316  Spaces 
Condition Code 11  X(3)  317  319  Spaces 
Condition Code 12  X(3)  320  322  Spaces 
Condition Code 13  X(3)  323  325  Spaces 
Condition Code 14  X(3)  326  328  Spaces 
Condition Code 15  X(3)  329  331  Spaces 
Condition Code 16  X(3)  332  334  Spaces 
Condition Code 17  X(3)  335  337  Spaces 
Condition Code 18  X(3)  338  340  Spaces 
Condition Code 19  X(3)  341  343  Spaces 
Condition Code 20  X(3)  344  346  Spaces 
Condition Code 21  X(3)  347  349  Spaces 
Condition Code 22  X(3)  350  352  Spaces 
Condition Code 23  X(3)  353  355  Spaces 
Condition Code 24  X(3)  356  358  Spaces 
Condition Code 25  X(3)  359  361  Spaces 
Condition Code 26  X(3)  362  364  Spaces 
Condition Code 27  X(3)  365  367  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
Condition Code 28  X(3)  368  370  Spaces 
Condition Code 29  X(3)  371  373  Spaces 
Condition Code 30  X(3)  374  376  Spaces 
Type of Bill  X(3)  377  379  Spaces 
Principal Diagnosis Code  X(7)  380  386  Spaces 
Other Diagnosis Code 1  X(7)  387  393  Spaces 
Other Diagnosis Code 2  X(7)  394  400  Spaces 
Other Diagnosis Code 3  X(7)  401  407  Spaces 
Other Diagnosis Code 4  X(7)  408  414  Spaces 
Other Diagnosis Code 5  X(7)  415  421  Spaces 
Other Diagnosis Code 6  X(7)  422  428  Spaces 
Other Diagnosis Code 7  X(7)  429  435  Spaces 
Other Diagnosis Code 8  X(7)  436  442  Spaces 
Other Diagnosis Code 9  X(7)  443  449  Spaces 
Other Diagnosis Code 10  X(7)  450  456  Spaces 
Other Diagnosis Code 11  X(7)  457  463  Spaces 
Other Diagnosis Code 12  X(7)  464  470  Spaces 
Other Diagnosis Code 13  X(7)  471  477  Spaces 
Other Diagnosis Code 14  X(7)  478  484  Spaces 
Other Diagnosis Code 15  X(7)  485  491  Spaces 
Other Diagnosis Code 16  X(7)  492  498  Spaces 
Other Diagnosis Code 17  X(7)  499  505  Spaces 
Other Diagnosis Code 18  X(7)  506  512  Spaces 
Other Diagnosis Code 19  X(7)  513  519  Spaces 
Other Diagnosis Code 20  X(7)  520  526  Spaces 
Other Diagnosis Code 21  X(7)  527  533  Spaces 
Other Diagnosis Code 22  X(7)  534  540  Spaces 
Other Diagnosis Code 23  X(7)  541  547  Spaces 
Other Diagnosis Code 24  X(7)  548  554  Spaces 
Principal Diagnosis Code Version         
Indicator Code  X(1)  555  555  Spaces 
Other Diagnosis Code 1 Version         
Indicator Code  X(1)  556  556  Spaces 
Other Diagnosis Code 2 Version         
Indicator Code  X(1)  557  557  Spaces 
Other Diagnosis Code 3 Version         
Indicator Code  X(1)  558  558  Spaces 
Other Diagnosis Code 4 Version         
Indicator Code  X(1)  559  559  Spaces 
Other Diagnosis Code 5 Version         
Indicator Code  X(1)  560  560  Spaces 
Other Diagnosis Code 6 Version         
Indicator Code  X(1)  561  561  Spaces 
Other Diagnosis Code 7 Version         
Indicator Code  X(1)  562  562  Spaces 
Other Diagnosis Code 8 Version         
Indicator Code  X(1)  563  563  Spaces 
Other Diagnosis Code 9 Version         
Indicator Code  X(1)  564  564  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
Other Diagnosis Code 10 Version         
Indicator Code  X(1)  565  565  Spaces 
Other Diagnosis Code 11 Version         
Indicator Code  X(1)  566  566  Spaces 
Other Diagnosis Code 12 Version         
Indicator Code  X(1)  567  567  Spaces 
Other Diagnosis Code 13 Version         
Indicator Code  X(1)  568  568  Spaces 
Other Diagnosis Code 14 Version         
Indicator Code  X(1)  569  569  Spaces 
Other Diagnosis Code 15 Version         
Indicator Code  X(1)  570  570  Spaces 
Other Diagnosis Code 16 Version         
Indicator Code  X(1)  571  571  Spaces 
Other Diagnosis Code 17 Version         
Indicator Code  X(1)  572  572  Spaces 
Other Diagnosis Code 18 Version         
Indicator Code  X(1)  573  573  Spaces 
Other Diagnosis Code 19 Version         
Indicator Code  X(1)  574  574  Spaces 
Other Diagnosis Code 20 Version         
Indicator Code  X(1)  575  575  Spaces 
Other Diagnosis Code 21 Version         
Indicator Code  X(1)  576  576  Spaces 
Other Diagnosis Code 22 Version         
Indicator Code  X(1)  577  577  Spaces 
Other Diagnosis Code 23 Version         
Indicator Code  X(1)  578  578  Spaces 
Other Diagnosis Code 24 Version         
Indicator Code  X(1)  579  579  Spaces 
Principal Procedure  X(7)  580  586  Spaces 
Principal Procedure Date  X(8)  587  594  Spaces 
Other Procedure 1  X(7)  595  601  Spaces 
Other Procedure 1 Date  X(8)  602  609  Spaces 
Other Procedure 2  X(7)  610  616  Spaces 
Other Procedure 2 Date  X(8)  617  624  Spaces 
Other Procedure 3  X(7)  625  631  Spaces 
Other Procedure 3 Date  X(8)  632  639  Spaces 
Other Procedure 4  X(7)  640  646  Spaces 
Other Procedure 4 Date  X(8)  647  654  Spaces 
Other Procedure 5  X(7)  655  661  Spaces 
Other Procedure 5 Date  X(8)  662  669  Spaces 
Other Procedure 6  X(7)  670  676  Spaces 
Other Procedure 6 Date  X(8)  677  684  Spaces 
Other Procedure 7  X(7)  685  691  Spaces 
Other Procedure 7 Date  X(8)  692  699  Spaces 
Other Procedure 8  X(7)  700  706  Spaces 
Other Procedure 8 Date  X(8)  707  714  Spaces 
Other Procedure 9  X(7)  715  721  Spaces 
Other Procedure 9 Date  X(8)  722  729  Spaces 
Other Procedure 10  X(7)  730  736  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
Other Procedure 10 Date  X(8)  737  744  Spaces 
Other Procedure 11  X(7)  745  751  Spaces 
Other Procedure 11 Date  X(8)  752  759  Spaces 
Other Procedure 12  X(7)  760  766  Spaces 
Other Procedure 12 Date  X(8)  767  774  Spaces 
Other Procedure 13  X(7)  775  781  Spaces 
Other Procedure 13 Date  X(8)  782  789  Spaces 
Other Procedure 14  X(7)  790  796  Spaces 
Other Procedure 14 Date  X(8)  797  804  Spaces 
Other Procedure 15  X(7)  805  811  Spaces 
Other Procedure 15 Date  X(8)  812  819  Spaces 
Other Procedure 16  X(7)  820  826  Spaces 
Other Procedure 16 Date  X(8)  827  834  Spaces 
Other Procedure 17  X(7)  835  841  Spaces 
Other Procedure 17 Date  X(8)  842  849  Spaces 
Other Procedure 18  X(7)  850  856  Spaces 
Other Procedure 18 Date  X(8)  857  864  Spaces 
Other Procedure 19  X(7)  865  871  Spaces 
Other Procedure 19 Date  X(8)  872  879  Spaces 
Other Procedure 20  X(7)  880  886  Spaces 
Other Procedure 20 Date  X(8)  887  894  Spaces 
Other Procedure 21  X(7)  895  901  Spaces 
Other Procedure 21 Date  X(8)  902  909  Spaces 
Other Procedure 22  X(7)  910  916  Spaces 
Other Procedure 22 Date  X(8)  917  924  Spaces 
Other Procedure 23  X(7)  925  931  Spaces 
Other Procedure 23 Date  X(8)  932  939  Spaces 
Other Procedure 24  X(7)  940  946  Spaces 
Other Procedure 24 Date  X(8)  947  954  Spaces 
Principal Procedure Version         
Indicator Code  X(1)  955  955  Spaces 
Other Procedure 1 Version Indicator        
Code  X(1)  956  956  Spaces 
Other Procedure 2 Version Indicator        
Code  X(1)  957  957  Spaces 
Other Procedure 3 Version Indicator        
Code  X(1)  958  958  Spaces 
Other Procedure 4 Version Indicator        
Code  X(1)  959  959  Spaces 
Other Procedure 5 Version Indicator        
Code  X(1)  960  960  Spaces 
Other Procedure 6 Version Indicator        
Code  X(1)  961  961  Spaces 
Other Procedure 7 Version Indicator        
Code  X(1)  962  962  Spaces 
Other Procedure 8 Version Indicator        
Code  X(1)  963  963  Spaces 
Other Procedure 9 Version Indicator        
Code  X(1)  964  964  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
Other Procedure 10 Version         
Indicator Code  X(1)  965  965  Spaces 
Other Procedure 11 Version         
Indicator Code  X(1)  966  966  Spaces 
Other Procedure 12 Version         
Indicator Code  X(1)  967  967  Spaces 
Other Procedure 13 Version         
Indicator Code  X(1)  968  968  Spaces 
Other Procedure 14 Version         
Indicator Code  X(1)  969  969  Spaces 
Other Procedure 15 Version         
Indicator Code  X(1)  970  970  Spaces 
Other Procedure 16 Version         
Indicator Code  X(1)  971  971  Spaces 
Other Procedure 17 Version         
Indicator Code  X(1)  972  972  Spaces 
Other Procedure 18 Version         
Indicator Code  X(1)  973  973  Spaces 
Other Procedure 19 Version         
Indicator Code  X(1)  974  974  Spaces 
Other Procedure 20 Version         
Indicator Code  X(1)  975  975  Spaces 
Other Procedure 21 Version         
Indicator Code  X(1)  976  976  Spaces 
Other Procedure 22 Version         
Indicator Code  X(1)  977  977  Spaces 
Other Procedure 23 Version         
Indicator Code  X(1)  978  978  Spaces 
Other Procedure 24 Version         
Indicator Code  X(1)  979  979  Spaces 
Claim Demonstration Identification         
Number  9(2)  980  981  Zeroes 
PPS Indicator  X(1)  982  982  Spaces 
Action Code  X(1)  983  983  Spaces 
Patient Status  X(2)  984  985  Spaces 
Billing Provider NPI  X(10)  986  995  Spaces 
Claim Provider Taxonomy Code  X(25)  996  1020  Spaces 
Medical Record Number  X(17)  1021  1037  Spaces 
Patient Control Number  X(20)  1038  1057  Spaces 
Attending Physician NPI  X(10)  1058  1067  Spaces 
Attending Physician Last Name  X(16)  1068  1083  Spaces 
Operating Physician NPI  X(10)  1084  1093  Spaces 
Operating Physician Last Name  X(16)  1094  1109  Spaces 
Claim Rendering Physician NPI  X(10)  1110  1119  Spaces 
Claim Rendering Physician Last         
Name  X(16)  1120  1135  Spaces 
Date of Admission  X(8)  1136  1143  Spaces 
Type of Admission  X(1)  1144  1144  Spaces 
Source of Admission  X(1)  1145  1145  Spaces 
DRG  X(3)  1146  1148  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
Occurrence Code 1  X(2)  1149  1150  Spaces 
Occurrence Code 1 Date  X(8)  1151  1158  Spaces 
Occurrence Code 2  X(2)  1159  1160  Spaces 
Occurrence Code 2 Date  X(8)  1161  1168  Spaces 
Occurrence Code 3  X(2)  1169  1170  Spaces 
Occurrence Code 3 Date  X(8)  1171  1178  Spaces 
Occurrence Code 4  X(2)  1179  1180  Spaces 
Occurrence Code 4 Date  X(8)  1181  1188  Spaces 
Occurrence Code 5  X(2)  1189  1190  Spaces 
Occurrence Code 5 Date  X(8)  1191  1198  Spaces 
Occurrence Code 6  X(2)  1199  1200  Spaces 
Occurrence Code 6 Date  X(8)  1201  1208  Spaces 
Occurrence Code 7  X(2)  1209  1210  Spaces 
Occurrence Code 7 Date  X(8)  1211  1218  Spaces 
Occurrence Code 8  X(2)  1219  1220  Spaces 
Occurrence Code 8 Date  X(8)  1221  1228  Spaces 
Occurrence Code 9  X(2)  1231  1230  Spaces 
Occurrence Code 9 Date  X(8)  1231  1238  Spaces 
Occurrence Code 10  X(2)  1239  1240  Spaces 
Occurrence Code 10 Date  X(8)  1241  1248  Spaces 
Occurrence Code 11  X(2)  1249  1250  Spaces 
Occurrence Code 11 Date  X(8)  1251  1258  Spaces 
Occurrence Code 12  X(2)  1259  1260  Spaces 
Occurrence Code 12 Date  X(8)  1261  1268  Spaces 
Occurrence Code 13  X(2)  1269  1270  Spaces 
Occurrence Code 13 Date  X(8)  1271  1278  Spaces 
Occurrence Code 14  X(2)  1279  1280  Spaces 
Occurrence Code 14 Date  X(8)  1281  1288  Spaces 
Occurrence Code 15  X(2)  1289  1290  Spaces 
Occurrence Code 15 Date  X(8)  1291  1298  Spaces 
Occurrence Code 16  X(2)  1299  1300  Spaces 
Occurrence Code 16 Date  X(8)  1301  1308  Spaces 
Occurrence Code 17  X(2)  1309  1310  Spaces 
Occurrence Code 17 Date  X(8)  1311  1318  Spaces 
Occurrence Code 18  X(2)  1319  1320  Spaces 
Occurrence Code 18 Date  X(8)  1321  1328  Spaces 
Occurrence Code 19  X(2)  1329  1330  Spaces 
Occurrence Code 19 Date  X(8)  1331  1338  Spaces 
Occurrence Code 20  X(2)  1339  1340  Spaces 
Occurrence Code 20 Date  X(8)  1341  1348  Spaces 
Occurrence Code 21  X(2)  1349  1350  Spaces 
Occurrence Code 21 Date  X(8)  1351  1358  Spaces 
Occurrence Code 22  X(2)  1359  1360  Spaces 
Occurrence Code 22 Date  X(8)  1361  1368  Spaces 
Occurrence Code 23  X(2)  1369  1370  Spaces 
Occurrence Code 23 Date  X(8)  1371  1378  Spaces 
Occurrence Code 24  X(2)  1379  1380  Spaces 
Occurrence Code 24 Date  X(8)  1381  1388  Spaces 
Occurrence Code 25  X(2)  1389  1390  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
Occurrence Code 25 Date  X(8)  1391  1398  Spaces 
Occurrence Code 26  X(2)  1399  1400  Spaces 
Occurrence Code 26 Date  X(8)  1401  1408  Spaces 
Occurrence Code 27  X(2)  1409  1410  Spaces 
Occurrence Code 27 Date  X(8)  1411  1418  Spaces 
Occurrence Code 28  X(2)  1419  1420  Spaces 
Occurrence Code 28 Date  X(8)  1421  1428  Spaces 
Occurrence Code 29  X(2)  1429  1430  Spaces 
Occurrence Code 29 Date  X(8)  1431  1438  Spaces 
Occurrence Code 30  X(2)  1439  1440  Spaces 
Occurrence Code 30 Date  X(8)  1441  1448  Spaces 
Value Code 1  X(2)  1449  1450  Spaces 
Value Amount 1  S9(8)V99  1451  1460  Zeroes 
Value Code 2  X(2)  1461  1462  Spaces 
Value Amount 2  S9(8)V99  1463  1472  Zeroes 
Value Code 3  X(2)  1473  1474  Spaces 
Value Amount 3  S9(8)V99  1475  1484  Zeroes 
Value Code 4  X(2)  1485  1486  Spaces 
Value Amount 4  S9(8)V99  1487  1496  Zeroes 
Value Code 5  X(2)  1497  1498  Spaces 
Value Amount 5  S9(8)V99  1499  1508  Zeroes 
Value Code 6  X(2)  1509  1510  Spaces 
Value Amount 6  S9(8)V99  1511  1520  Zeroes 
Value Code 7  X(2)  1521  1522  Spaces 
Value Amount 7  S9(8)V99  1523  1532  Zeroes 
Value Code 8  X(2)  1533  1534  Spaces 
Value Amount 8  S9(8)V99  1535  1544  Zeroes 
Value Code 9  X(2)  1545  1546  Spaces 
Value Amount 9  S9(8)V99  1547  1556  Zeroes 
Value Code 10  X(2)  1557  1558  Spaces 
Value Amount 10  S9(8)V99  1559  1568  Zeroes 
Value Code 11  X(2)  1569  1570  Spaces 
Value Amount 11  S9(8)V99  1571  1580  Zeroes 
Value Code 12  X(2)  1581  1582  Spaces 
Value Amount 12  S9(8)V99  1583  1592  Zeroes 
Value Code 13  X(2)  1593  1594  Spaces 
Value Amount 13  S9(8)V99  1595  1604  Zeroes 
Value Code 14  X(2)  1605  1606  Spaces 
Value Amount 14  S9(8)V99  1607  1616  Zeroes 
Value Code 15  X(2)  1617  1618  Spaces 
Value Amount 15  S9(8)V99  1619  1628  Zeroes 
Value Code 16  X(2)  1629  1630  Spaces 
Value Amount 16  S9(8)V99  1631  1640  Zeroes 
Value Code 17  X(2)  1641  1642  Spaces 
Value Amount 17  S9(8)V99  1643  1652  Zeroes 
Value Code 18  X(2)  1653  1654  Spaces 
Value Amount 18  S9(8)V99  1655  1664  Zeroes 
Value Code 19  X(2)  1665  1666  Spaces 
Value Amount 19  S9(8)V99  1667  1676  Zeroes 
Value Code 20  X(2)  1677  1678  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
Value Amount 20  S9(8)V99  1679  1688  Zeroes 
Value Code 21  X(2)  1689  1690  Spaces 
Value Amount 21  S9(8)V99  1691  1700  Zeroes 
Value Code 22  X(2)  1701  1702  Spaces 
Value Amount 22  S9(8)V99  1703  1712  Zeroes 
Value Code 23  X(2)  1713  1714  Spaces 
Value Amount 23  S9(8)V99  1715  1724  Zeroes 
Value Code 24  X(2)  1725  1726  Spaces 
Value Amount 24  S9(8)V99  1727  1736  Zeroes 
Value Code 25  X(2)  1737  1738  Spaces 
Value Amount 25  S9(8)V99  1739  1748  Zeroes 
Value Code 26  X(2)  1749  1750  Spaces 
Value Amount 26  S9(8)V99  1751  1760  Zeroes 
Value Code 27  X(2)  1761  1762  Spaces 
Value Amount 27  S9(8)V99  1763  1772  Zeroes 
Value Code 28  X(2)  1773  1774  Spaces 
Value Amount 28  S9(8)V99  1775  1784  Zeroes 
Value Code 29  X(2)  1785  1786  Spaces 
Value Amount 29  S9(8)V99  1787  1796  Zeroes 
Value Code 30  X(2)  1797  1798  Spaces 
Value Amount 30  S9(8)V99  1799  1808  Zeroes 
Value Code 31  X(2)  1809  1810  Spaces 
Value Amount 31  S9(8)V99  1811  1820  Zeroes 
Value Code 32  X(2)  1821  1822  Spaces 
Value Amount 32  S9(8)V99  1823  1832  Zeroes 
Value Code 33  X(2)  1833  1834  Spaces 
Value Amount 33  S9(8)V99  1835  1844  Zeroes 
Value Code 34  X(2)  1845  1846  Spaces 
Value Amount 34  S9(8)V99  1847  1856  Zeroes 
Value Code 35  X(2)  1857  1858  Spaces 
Value Amount 35  S9(8)V99  1859  1868  Zeroes 
Claim Final Allowed Amount  S9(8)V99  1869  1878  Zeroes 
Claim Deductible Amount  S9(8)V99  1879  1888  Zeroes 
Claim State  X(2)  1889  1890  Spaces 
Claim Zip Code  X(9)  1891  1899  Spaces 
Beneficiary State  X(2)  1900  1901  Spaces 
Beneficiary Zip Code  X(9)  1902  1910  Spaces 
Claim PWK  X(60)  1911  1970  Spaces 
Patient Reason for Visit 1  X(7)  1971  1977  Spaces 
Patient Reason for Visit 2  X(7)  1978  1984  Spaces 
Patient Reason for Visit 3  X(7)  1985  1991  Spaces 
Patient Reason for Visit 1 Version    1992  1992   
Indicator Code  X(1)  Spaces 
Patient Reason for Visit 2 Version    1993  1993   
Indicator Code  X(1)  Spaces 
Patient Reason for Visit 3 Version    1994  1994   
Indicator Code  X(1)  Spaces 
Present on Admission/External    1995  2031   
Cause of Injury Indicator  X(37)  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
External Cause of Injury 1  X(7)  2032  2038  Spaces 
External Cause of Injury 2  X(7)  2039  2045  Spaces 
External Cause of Injury 3  X(7)  2046  2052  Spaces 
External Cause of Injury 4  X(7)  2053  2059  Spaces 
External Cause of Injury 5  X(7)  2060  2066  Spaces 
External Cause of Injury 6  X(7)  2067  2073  Spaces 
External Cause of Injury 7  X(7)  2074  2080  Spaces 
External Cause of Injury 8  X(7)  2081  2087  Spaces 
External Cause of Injury 9  X(7)  2088  2094  Spaces 
External Cause of Injury 10  X(7)  2095  2101  Spaces 
External Cause of Injury 11  X(7)  2102  2108  Spaces 
External Cause of Injury 12  X(7)  2109  2115  Spaces 
External Cause of Injury 1 Version    2116  2116   
Indicator Code  X(1)  Spaces 
External Cause of Injury 2 Version    2117  2117   
Indicator Code  X(1)  Spaces 
External Cause of Injury 3 Version    2118  2118   
Indicator Code  X(1)  Spaces 
External Cause of Injury 4 Version    2119  2119   
Indicator Code  X(1)  Spaces 
External Cause of Injury 5 Version    2120  2120   
Indicator Code  X(1)  Spaces 
External Cause of Injury 6 Version    2121  2121   
Indicator Code  X(1)  Spaces 
External Cause of Injury 7 Version    2122  2122   
Indicator Code  X(1)  Spaces 
External Cause of Injury 8 Version    2123  2123   
Indicator Code  X(1)  Spaces 
External Cause of Injury 9 Version    2124  2124   
Indicator Code  X(1)  Spaces 
External Cause of Injury 10 Version   2125  2125   
Indicator Code  X(1)  Spaces 
External Cause of Injury 11 Version   2126  2126   
Indicator Code  X(1)  Spaces 
External Cause of Injury 12 Version   2127  2127   
Indicator Code  X(1)  Spaces 
Service Facility Zip Code  X(9)  2128  2136  Spaces 
RAC adjustment indicator  X(1)  2137  2137  Spaces 
Split/Adjustment Indicator  9(2)  2138  2139  Spaces 
Referring Physician NPI  X(10)  2140  2149  Spaces 
Referring Physician Last Name  X(16)  2150  2165  Spaces 
Referring Physician Specialty  X(2)  2166  2167  Spaces 
Claim Rendering Physician  X(2)  2168  2169  Spaces 
Overpay Indicator  X(1)  2170  2170  Spaces 
Overpay Code  X(3)  2171  2173  Spaces 
Claim Demonstration Identification  X(2)  2174  2175  Spaces 
Number 2 
Claim Demonstration Identification  X(2)  2176  2177  Spaces 
Number 3 
     
Field Name  Picture  From  Thru  Initialization 
Claim Demonstration Identification  X(2)  2178  2179  Spaces 
Number 4 
Beneficiary MBI  X(11)  2180  2190  Spaces 
MBI/HICN Indicator  X(1)  2191  2191  Spaces 
Filler  X(10)  2192  2201  Spaces 
Total Line Item Count  9(3)  2202  2204  Zeroes 
Record Line Item Count  9(3)  2205  2207  Zeroes 
 
Sampled Claims Resolution File 
Sampled Claims Resolution Claim Line Item Group Record 
*The following group of fields occurs from 1 to 450 times for the 
claim (depending on Total Line Item Count) and 1 to 75 times 
for the Record (depending on Record Line Item Count) 
st 
*From and Thru values relate to the 1 line item 
 
Field Name  Picture  From  Thru  Initialization 
Revenue center code  X(4)  2208  2211  Spaces 
SNF-RUG-III code  X(3)  2212  2214  Spaces 
APC adjustment code  X(5)  2215  2219  Spaces 
HCPCS Procedure Code  X(5)  2220  2224  Spaces 
HCPCS Modifier 1  X(2)  2225  2226  Spaces 
HCPCS Modifier 2  X(2)  2227  2228  Spaces 
HCPCS Modifier 3  X(2)  2229  2230  Spaces 
HCPCS Modifier 4  X(2)  2231  2232  Spaces 
HCPCS Modifier 5  X(2)  2233  2234  Spaces 
Line Item Date  X(8)  2235  2242  Spaces 
Line Submitted Charge  S9(8)V99  2243  2252  Zeroes 
Line Medicare Initial Allowed  S9(8)V99  2253  2262  Zeroes 
ANSI Reason Code 1  X(8)  2263  2270  Spaces 
ANSI Reason Code 2  X(8)  2271  2278  Spaces 
ANSI Reason Code 3  X(8)  2279  2286  Spaces 
ANSI Reason Code 4  X(8)  2287  2294  Spaces 
ANSI Reason Code 5  X(8)  2295  2302  Spaces 
ANSI Reason Code 6  X(8)  2303  2310  Spaces 
ANSI Reason Code 7  X(8)  2311  2318  Spaces 
ANSI Reason Code 8  X(8)  2319  2326  Spaces 
ANSI Reason Code 9  X(8)  2327  2334  Spaces 
ANSI Reason Code 10  X(8)  2335  2342  Spaces 
ANSI Reason Code 11  X(8)  2343  2350  Spaces 
ANSI Reason Code 12  X(8)  2351  2358  Spaces 
ANSI Reason Code 13  X(8)  2359  2366  Spaces 
ANSI Reason Code 14  X(8)  2367  2374  Spaces 
Manual Medical Review Indicator  X(1)  2375  2375  Spaces 
Resolution Code  X(5)  2376  2380  Spaces 
 
 
Field Name  Picture  From  Thru  Initialization 
Line Final Allowed Charge  S9(8)V99  2381  2390  Zeroes 
Line Cash Deductible  S9(8)V99  2391  2400  Zeroes 
Special Action Code/Override Code  X(1)  2401  2401  Zeroes 
     
Units  S9(7)v999  2402  2411  Zeroes 
Rendering Physician NPI  X(10)  2412  2421  Spaces 
Rendering Physician Last Name  X(25)  2422  2446  Spaces 
National Drug Code (NDC) field  X(11)  2447  2457  Spaces 
National Drug Code (NDC)  S9(7)v999  2458  2467  Spaces 
National Drug Code (NDC)         
Quantity Qualifier  X(2)  2468  2469  Spaces 
Line PWK  X(60)  2470  2529  Spaces 
Line Rendering Physician specialty  X(2)  2530  2531  Spaces 
Prior Authorization Program  X(4)  2532  2535  Spaces 
Unique Tracking Number (UTN)  X(14)  2536  2549  Spaces 
Prior Authorization Affirmed  X(1)  2550  2550  Spaces 
Filler  X(4)  2551  2554  Spaces 
 
DATA ELEMENT DETAIL 
 
Claim (Header) Fields 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number.  
Validation:  Must be a valid CMS contractor ID.  
Remarks:  N/A 
Requirement:   Required 
NOTE:  For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor 
ID specified by CMS. 
 
Data Element: Record Type 
Definition:  Code indicating type of record  
Validation:  N/A 
Remarks:  2 = Claim record  
Requirement:   Required 
 
Data Element:   Record Version Code 
Definition:  The code indicating the record version of the Claim Resolution file  
Validation:  Claim Resolution files prior to 10/1/2007 did not contain this field. 
Codes: 
B = Record Format as of 10/1/2007  
C = Record Format as of 1/1/2010  
D = Record Format as of 10/1/2012  
E = Record Format as of 7/1/2016  
F = Record Format as of 10/1/2017 
Remarks:  N/A  
Requirement: Required 
 
Data Element:   Contractor Type 
 
Definition:  Type of Medicare Contractor included in the file  
Validation:  Must be A or R 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
 
     
Data Element: Record Number 
Definition:  The sequence number of the record. A claim may have up to six records. 
Validation:  Must be between 1 and 6 
Remarks:  None Requirement: Required 
 
Data Element: Mode of Entry Indicator 
Definition:  Code that indicates if the claim is paper, EMC, or unknown  
Validation:  Must be 'E, 'P, or 'U' 
Remarks:  E = EMC  
  P = Paper 
U= Unknown 
Use the same criteria to determine EMC, paper, or unknown as that used for 
workload reporting 
Requirement:   Required 
 
Data Element:   Original Claim Control Number 
Definition:  The Claim Control Number the shared system assigned to the claim in the 
Universe file. This number should be the same as the claim control number 
for the claim in the Sample Claims Transactions file, and the claim control 
number for the claim on the Universe file. If the shared system had to use a 
crosswalk to pull the claim because the MAC or shared system changed the 
claim control number during processing, enter the number the shared system 
used to look up the number needed to pull all records associated with the 
sample claim. 
Validation:  For all records in the resolution file, the Original Claim Control must match the 
Claim Control Number identified in the Sampled Claims Transaction File. 
Remarks:  N/A  
Requirement:   Required 
   
Data Element: Internal Control Number 
Definition:  Number currently assigned by the Shared System to uniquely identify the claim. 
Validation:  N/A 
Remarks:  Use the Original Claim Control Number if no adjustment has been made to the 
claim. This number may be different from the Original Claim Control Number 
if the shared system has assigned a new Claims Control Number to an 
adjustment to the claim requested. 
Requirement:   Required 
 
Data Element: Beneficiary HICN 
Definition:  Beneficiarys Health Insurance Claim Number  
Validation:  N/A 
Remarks:  N/A 
Requirement:   Required 
 
Data Element: Beneficiary Last Name 
Definition:  Last Name (Surname) of the beneficiary  
Validation:  N/A 
Remarks:  N/A  
Requirement:   Required 
 
Data Element: Beneficiary First Name 
Definition:  First (Given) Name of the beneficiary  
Validation:  N/A 
Remarks:  N/A  
Requirement:   Required 
 
     
Data Element: Beneficiary Middle Initial 
Definition:  First letter from Beneficiary Middle Name  
Validation:  N/A 
Remarks
:    N/A  
Requirement:   Required 
 
Data Element: Beneficiary Date of Birth  
Definition:  Birth date of the beneficiary  
Validation:  Must be a valid date 
Remarks:  MMDDCCYY on which the beneficiary was born  
Requirement:   Required 
 
Data Element: Beneficiary Gender  
Definition:    Gender of the beneficiary 
Validation:  'M' = Male, 'F' = Female, or 'U' = Unknown  
Remarks:  N/A 
Requirement:   Required 
 
Data Element: Billing Provider Number 
Definition:  First nine characters of number used to identify the billing/pricing provider or 
supplier. 
Validation:  Must be present 
If the same billing/pricing provider number does not apply to all lines on the 
claim, enter the Billing provider number that applies to the first line of the claim. 
Remarks:  N/A 
Requirement:  Required for all claims 
 
Data Element: Attending Physician UPIN 
Definition:  The UPIN submitted on the claim used to identify the physician that is 
responsible for coordinating the care of the patient while in the facility. 
Validation:  N/A  
Remarks:   Left justify 
Requirement:   Required when available on claim record. 
 
Data Element: Claim Paid Amount 
Definition:  Amount of payment made from the Medicare trust fund for the services 
covered by the claim record. Generally, the amount is calculated by the A/B 
MAC (A) or A/B MAC (B) and represents what CMS paid to the institutional 
provider, physician, or supplier, i.e. The Claim Paid Amount is the net amount 
paid after co-insurance and deductibles are applied. 
Validation:  N/A  
Remarks:  N/A  
Requirement: Required 
 
Data Element: Claim ANSI Reason Code 1-7 
Definition:  Codes showing the reason for any adjustments to this claim, such as denials 
or reductions of payment from the amount billed. 
Validation:  Must be valid American National Standards Institute (ANSI) Ambulatory 
Surgical Center (ASC) claim adjustment code and applicable group code. 
Remarks:  Format is GGRRRRRR where: GG is the group code and RRRRRR is the 
adjustment reason code. 
Requirement:   Report all ANSI reason codes on the bill 
 
Data Element: Statement Covers from Date  
Definition:  The beginning date of the statement  
     
Validation:  Must be a valid date 
Remarks:  Format must be CCYYMMDD  
Requirement:   Required 
 
Data Element: Statement Covers thru Date  
Definition:  The ending date of the statement  
Validation:  Must be a valid date 
Remarks:  Format must be CCYYMMDD  
Requirement:   Required 
 
Data Element: Claim Entry Date 
Definition:  Date claim entered the shared claim processing system, the receipt date  
Validation:  Must be a valid date 
Remarks:  Format must be CCYYMMDD  
Requirement:   Required 
 
Data Element: Claim Adjudicated Date 
Definition:  Date claim completed adjudication, i.e., process date  
Validation:  Must be a valid date 
Remarks:  Format must be CCYYMMDD Requirement: Required 
 
Data Element: Condition Code 1 -30 
Definition:  The code that indicates a condition relating to an institutional claim that may 
affect payer processing 
Validation:  Must be a valid code as listed in Pub 100-4, Medicare Claims Processing 
Manual, Chapter 25, Completing and Processing CMS-1450 Data Set. 
Remarks:  This field is left justified and blank filled.  
Requirement:   Required if there is a condition code for the bill. 
Data Element: Type of Bill 
Definition:  A code indicating the specific type of bill (hospital, inpatient, SNF, outpatient, 
adjustments, voids, etc.).  This three-digit alphanumeric code gives three 
specific pieces of information. The first digit identifies the type of facility. The 
second classifies the type of care. The third indicates the sequence of this bill 
in this particular episode of care. It is referred to as frequency code. 
Validation:  Must be a valid code as listed in Pub 100-4, Medicare Claims Processing 
Manual, Chapter 25, Completing and Processing CMS-1450 Data Set 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Principal Diagnosis 
Definition:  The current version of ICD--CM diagnosis code identifying the diagnosis, 
condition, problem or other reason for the admission/encounter/visit shown in 
the medical record to be chiefly responsible for the services provided. 
Validation:  Must be a valid ICD--CM diagnosis code 
  CMS accepts only CMS approved ICD--CM diagnostic and  
procedural codes. The CMS approves only changes issued by the Federal 
ICD-- CM Coordination and Maintenance Committee. 
  Diagnosis codes must be full ICD--CM diagnoses codes, including 
the full number of digits (five for ICD-9-CM, seven for ICD-10-CM) where 
applicable. 
Remarks:  The principal diagnosis is the condition established after study to be chiefly 
responsible for this admission. Even though another diagnosis may be more 
severe than the principal diagnosis, the principal diagnosis, as defined above, 
is entered. 
Requirement:   Required 
 
     
Data Element:   Principal Diagnosis Version Indicator Code 
Definition:  The diagnosis version code identifying the version of ICD diagnosis code 
submitted.  
Validation: 
  Version ICD9 use Version Code 9 
  Version ICD10 use Version Code 0 
Remarks:  With the exception of claims submitted by ambulance suppliers (specialty). 
Requirement:   Principal Diagnosis Version Code 1 is required for ALL claims. 
 
Data Element: Other Diagnosis Code 1-24 
Definition:   The ICD-CM diagnosis code identifying the diagnosis, condition, problem or 
other  
reason for the admission/encounter/visit shown in the medical record to be 
present during treatment. 
Validation:  Must be a valid ICD--CM diagnosis code 
  CMS accepts only CMS approved ICD-CM diagnostic and procedural codes. 
The CMS approves only changes issued by the Federal ICD-CM Coordination 
and Maintenance Committee. 
  Diagnosis codes must be full ICD-CM diagnoses codes, including The full 
number of digits (five for ICD-9-CM, seven for ICD-10-CM) where applicable. 
Remarks:  Report the full ICD-CM codes for up to 24 additional conditions if they co-
existed at the time of admission or developed subsequently, and which had 
an effect upon the treatment or the length of stay. 
Requirement: Required if available on the claim record. 
 
Data Element:   Other Diagnosis Version Indicator Code 1-24 
Definition:  The ICD-CM diagnosis version code identifying the version of diagnosis code 
submitted. 
Validation: 
  Version ICD9 use Version Code 9 
  Version ICD10 use Version Code 0 
Remarks:  N/A 
Requirement:   Principal Diagnosis Version Code 1 is required for ALL claims. Other 
Diagnosis version codes 1-24 should be submitted to correspond to claim 
level diagnosis codes 1-24. 
 
Data Element: Principal Procedure and Date 
Definition:  The ICD--CM code that indicates the principal procedure performed during the 
period covered by the institutional claim. And the Date on which it was 
performed. 
Validation:  Must be a valid ICD--CM procedure code 
  CMS accepts only CMS approved ICD--CM diagnostic and 
procedural codes. The CMS approves only changes issued by the Federal 
ICD--CM Coordination and Maintenance Committee. 
  The procedure code shown must be the full ICD--CM, Volume 3,  
procedure code, including the full number of digits (five for ICD-9-CM, seven 
for ICD-10-CM). 
Remarks:  The principal procedure is the procedure performed for definitive treatment 
rather than for diagnostic or exploratory purposes, or which was necessary to 
take care of a complication. It is also the procedure most closely related to 
the principal diagnosis. 
     
  The date applicable to the principal procedure is shown numerically as 
CCYYMMDD in the date portion. 
Requirement:   Required for inpatient claims. 
 
Data Element:   Principal Procedure Version Indicator Code 
Definition:  The version code identifying the version of ICD procedure code submitted. 
Validation: 
  Version ICD9 use Version Code 9 
  Version ICD10 use Version Code 0 
Remarks:  N/A 
Requirement: Principal Procedure Code Version Code is required for ALL claims containing a
  Principal Procedure. 
 
Data Element: Other Procedure and Date 1-24 
Definition:  The ICD-CM code identifying the procedure, other than the principal 
procedure, performed during the billing period covered by this bill. 
Validation:  Must be a valid ICD-CM procedure code 
  CMS accepts only CMS approved ICD-CM diagnostic and 
procedural codes. The CMS approves only changes issued by the Federal ICD-
CM Coordination and Maintenance Committee. 
  The procedure code shown must be the full ICD-CM, Volume 3, procedure 
code, including the full number of digits (five for ICD-9-CM, seven for ICD-10-
CM). 
Remarks:  The date applicable to the procedure is shown numerically as CCYYMMDD in 
the date portion. 
Requirement:   Required if on claim record. 
 
Data Element:   Other Procedure Code Version Indicator Code 1-24 
Definition:  The ICD-CM diagnosis version code identifying the version of procedure code 
submitted 
Validation: 
  Version ICD9 use Version Code 9 
  Version ICD10 use Version Code 0 
Remarks:  N/A 
Requirement:   Principal Procedure Version Code is required for ALL claims. Other 
Procedure version codes 1-24 should be submitted to correspond to other 
procedure code 1-24. 
 
Data Element: Claim Demonstration Identification Number 
Definition:  The number assigned to identify a demonstration project.  
Validation:  Must be numeric or zeroes 
Remarks:  This field contains the value from the first populated 
demonstration field.  
Requirement:   Required for all claims involved in a 
demonstration project 
 
Data Element: PPS Indicator 
Definition:  The code indicating whether (1) the claim is Prospective Payment System 
(PPS) or not PPS.  
Validation:  0 = Not PPS 
1 = PPS 
Remarks:  N/A  
Requirement: Required 
     
 
Data Element: Action Code 
Definition:  Indicator identifying the type of action requested by the intermediary to be 
taken on an institutional claim. 
Validation:  Must be a valid action code. 
1 = Original debit action (includes non-adjustment RTI correction items) 
 it will always be a 1 in regular bills. 
2 = Cancel by credit adjustment  used only in credit/debit pairs (under 
HHPPS, updates the RAP). 
3 = Secondary debit adjustment - used only in credit/debit pairs (under 
HHPPS, would be the final claim or an adjustment on a LUPA). 
4 = Cancel only adjustment (under HHPPS, RAP/final claim/LUPA).  
5 = Force action code 3. 
6 = Force action code 2. 
8 = Benefits refused (for inpatient bills, an 'R' nonpayment code must also be 
present. 
9 = Payment requested (used on bills that replace previously-submitted 
benefits- refused bills, action code 8. In such cases a debit/credit pair is 
not required. For inpatient bills, a 'P' should be entered in the 
nonpayment code.) 
Remarks:  N/A 
Requirement:   Required 
 
Data Element: Patient Status 
Definition:  This code indicates the patients status as of the Through 
date of the billing period. 
Validation:  Must be a valid code as listed in Pub 100-4, Medicare Claims 
Processing  Manual, Chapter 25, Completing and Processing CMS-1450 Data 
Set. 
Remarks:  N/A  
Requirement:   Required 
 
Data Element: Billing Provider NPI 
Definition:  NPI assigned to the Billing Provider.  
Validation:  N/A 
Remarks:  N/A. 
Requirement:   Required for providers using HIPAA standard transactions 
 
Data Element: Claim Provider Taxonomy Code 
Definition:  The non-medical data code set used to classify health care providers 
according to provider type or practitioner specialty in an electronic 
environment, specifically within the American National Standards Institute 
Accredited Standards Committee health care transaction. 
Validation:  Must be present 
  If multiple taxonomy codes are associated with a provider  
number, provide the first one in sequence. 
Remarks:  N/A 
Requirement:   Required when available. 
 
Data Element:   Medical Record Number 
Definition:  Number assigned to patient by hospital or other provider to assist in retrieval 
of medical records. 
Validation:  N/A 
Remarks:  N/A 
Requirement:   Required if available on claim record 
 
     
Data Element: Patient Control Number 
Definition:  The patients unique alpha-numeric control number assigned by the provider 
to facilitate retrieval of individual financial records and posting payment. 
Validation:  N/A 
Remarks:  N/A 
Requirement:   Required if available on claim record 
 
Data Element: Attending Physician NPI 
Definition:  NPI assigned to the Attending Physician.  
Validation:  N/A 
Remarks:  Left justify 
Requirement:   Required when available on claim record. 
 
Data Element: Attending Physician Last Name 
Definition:  Last Name (Surname) of the attending physician.  
Validation:  Must be present 
 
Remarks:  N/A 
Requirement: Required when available on claim record 
 
Data Element: Operating Physician NPI 
Definition:  NPI assigned to the Operating Physician.  
Validation:  N/A 
Remarks:  Left justify 
Requirement:   Required when available on claim record. 
 
Data Element: Operating Physician Last Name 
Definition:  Last Name (Surname) of the operating physician.  
Validation:  Must be present 
Remarks:  N/A 
Requirement:   Required when available on claim record 
 
Data Element: Claim Rendering Physician NPI 
Definition:  NPI assigned to the claim rendering physician (mapped from 2310D from the 
837I version 5010A2). 
Validation:  N/A 
Remarks:  Left justify 
Requirement:   Required when available on claim record. 
 
Data Element: Claim Rendering Physician Last Name 
Definition:  Last Name (Surname) of the claim rendering physician (mapped from 2310D 
from the 837I version 5010A2). 
Validation:  Must be present  
Remarks:  N/A 
Requirement:   Required when available on claim record 
 
Data Element: Date of Admission 
Definition:  The date the patient was admitted to the provider for inpatient care, 
outpatient service, or start of care. For an admission notice for hospice care, 
enter the effective date of election of hospice benefits. 
Validation:  Must be a valid date  
Remarks:  Format date as CCYYDDD  
Requirement:   Required if on claim record. 
 
Data Element: Type of Admission 
     
Definition:  The code indicating the type and priority of an inpatient admission associated 
with the service on an intermediary claim. 
Validation:  Must be a valid code as listed in Pub 100-4, Medicare Claims 
Processing Manual, Chapter 25, Completing and Processing 
CMS-1450 Data Set Code Structure. 
Remarks:  N/A 
Requirement:   Required on inpatient claims only. 
 
Data Element: Source of Admission 
Definition:  The code indicating the means by which the beneficiary was admitted to the 
inpatient health care facility or SNF if the type of admission is (1) emergency, 
(2) urgent, or (3) elective. 
Validation:  Must be a valid code as listed in Pub 100-4, Medicare Claims Processing 
Manual, Chapter 25, Completing and Processing CMS-1450 Data Set Code 
Structure (For Emergency, Elective, or Other Type of Admission) 
Remarks:  N/A 
Requirement:   Required when entered on the claim record. 
 
Data Element:   DRG (Diagnosis Related Group) 
Definition:  The code identifying the diagnostic related group to which a hospital claim 
belongs for prospective payment purposes. 
Validation:  Must be valid per the DRG DEFINITIONS MANUAL  
Remarks:  N/A 
Requirement:   Required if available on the claim record 
 
Data Element: Occurrence Code and Date 1-30 
Definition:  Code(s) and associated date(s) defining specific event(s) relating to this 
billing period are shown. 
Validation:  Must be a valid code as listed in Pub 100-4, Medicare Claims 
Processing Manual, Chapter 25, Completing and Processing 
CMS-1450 Data Set. 
Remarks: 
  Event codes are two alpha-numeric digits, and dates are shown as eight  
  numeric digits (MM-DD-CCYY) 
  When occurrence codes 01-04 and 24 are entered, make sure the entry  
  includes the appropriate value codes, if there is another  payer 
involved. 
Requirement:   Required if available on claim record 
 
Data Element: Value Codes and Amounts 1-35 
Definition:  Code(s) and related dollar or unit amount(s) identify data of a monetary 
nature that are necessary for the processing of this claim. 
Validation:  Must be a valid code as listed in Pub 100-4, Medicare Claims Processing 
Manual, Chapter 25, Completing and Processing CMS-1450 Data Set. 
Remarks: 
  The codes are two alpha-numeric digits, and each value allows  
up to nine numeric digits (0000000.00). 
  Negative amounts are not allowed except in the last entry. 
  Whole numbers or non-dollar amounts are right justified to the left of the 
dollars and cents delimiter. 
  Some values are reported as cents, so refer to specific codes for 
instructions. 
  If more than one value code is shown for a billing period, codes are shown in 
     
ascending numeric sequence. 
  Use the first line before the second, etc. 
Requirement: Required if available on claim record 
 
Data Element: Claim Final Allowed Amount  
Definition:  Final Allowed Amount for this claim.  
Validation:  N/A 
Remarks:  The Gross Allowed charges on the claim. This represents the amount paid to 
the provider plus any beneficiary responsibility (co-pay and deductible) 
Requirement:   Required 
 
Data Element: Claim Deductible Amount 
Definition:  Amount of deductible applicable to the claim.  
Validation:  N/A 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Claim State 
Definition:  2 character indicator showing the state where the service is furnished. 
Validation:  Must be a valid USPS state abbreviation 
Remarks:  N/A  
Requirement:   Required 
 
Data Element:   Claim Zip Code 
Definition:  Zip code of the physical location where the services were furnished.  
Validation:  Must be a valid USPS zip code. 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Beneficiary State 
Definition:  2 character indicator showing the state of beneficiary residence.  
Validation:  Must be a valid USPS state abbreviation 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Beneficiary Zip Code 
Definition:  Zip code associated with the beneficiary residence.  
Validation:  Must be a valid USPS zip code. 
Remarks:  N/A  
Requirement: Required 
 
Data Element: PWK Filler 
Definition:  PWK space -- use to be determined  
Validation:  N/A 
Remarks:  N/A 
Requirement:   Required when available on claim. 
 
Data Element: Patient Reason for Visit 1-3 
Definition:  An ICD--CM code on the institutional claim indicating the beneficiary's reason 
for visit. 
Validation:  Must be a valid ICD-CM diagnosis code. 
  CMS accepts only CMS approved ICD-CM diagnostic and 
procedural codes. The CMS approves only changes issued by the Federal  
ICD-CM Coordination and Maintenance Committee. 
  Diagnosis codes must be full ICD-CM diagnoses codes,  
     
including the full number of digits (five for ICD-9-CM, seven  
for ICD-10- CM) where applicable. 
Remarks:  Report the full ICD-CM codes for up to 3 conditions responsible for the 
patients visit. 
 
Requirement: For OP claims, this field is populated for those claims that are required to 
process  
through OP PPS Pricer. The type of bills (TOB) required to process through 
are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, 
hospitals located in American Samoa, Guam and Saipan and Critical Access 
Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any 
outpatient type of bill with a condition code '07' and certain HCPCS. These 
claim types could have lines that are not required to price under OPPS rules 
so those lines would not have data in this field. Additional exception: Virgin 
Island hospitals and hospitals that furnish only inpatient Part B services. 
 
Data Element:   Patient Reason for Visit Version Indicator Code 1-3 
Definition:  The ICD-CM diagnosis version code identifying the version of diagnosis code 
submitted. 
Validation: 
  Version ICD9 use Version Code 9 
  Version ICD10 use Version Code 0 
Remarks:  N/A 
Requirement:   Patient Reason for Visit Version codes must be submitted to 
correspond to patient reason for visit codes 1-3. 
 
Data Element: Present on Admission/External Cause of Injury Indicator 
Definition:  The code used to indicate a condition was present at the time the beneficiary 
was admitted to a general acute care facility. 
Validation:  Position 1 for Principle Diagnosis, positions 2-25 for the 24 Secondary 
Diagnosis for the Present on Admission (POA) Indicator, Positions 26  37 for 
the 12 External Cause of Injury. 
Remarks:  N/A  
Requirement: Required 
 
Data Element: External Cause of Injury Diagnosis Codes 1-12 
Definition:  The ICD-CM code used to identify the external cause of injury, 
poisoning, or other adverse effect. 
Validation:  Must be a valid ICD--CM diagnosis code. 
  CMS accepts only CMS approved ICD-CM diagnostic and procedural codes. 
The CMS approves only changes issued by the Federal ICD-CM Coordination 
and Maintenance Committee. 
  Diagnosis codes must be full ICD-CM diagnoses codes, including the full 
number of digits (five for ICD-9-CM, seven for ICD-10- CM) where applicable. 
Remarks:  Report the full ICD-CM codes for up to 12 conditions resulting from external 
causes. 
Requirement: Required if available on the claim record. 
 
Data Element:   External Cause of Injury Version Indicator Code 1-12 
Definition:  The ICD-CM diagnosis version code identifying the version of diagnosis code 
identified as external cause of injury. 
 
Validation: 
  Version ICD9 use Version Code 9 
     
  Version ICD10 use Version Code 0 
Remarks:  N/A 
Requirement: External Cause of Injury version codes 1-12 should be submitted to 
correspond to external cause of injury diagnosis codes 1-12. 
 
Data Element:  Service Facility Zip Code 
Definition:  Zip Code used to identify were the service was furnished.  
Validation:  Must be a valid Zip Code 
Remarks:  N/A 
Requirement: Required, if available on claim record. 
 
Data Element: RAC Adjustment Indicator 
Definition:  Indicator used to identify RAC requested adjustments, which occur as a  
  result of post-payment review activities done by the Recovery Audit  
  Contractors (RAC). 
Validation:  R identifies a RAC-requested adjustment  
Remarks:  N/A 
Requirement: Required when RAC adjustment indicator was furnished to CWF. 
 
Data Element: Split/Adjustment Indicator 
Definition:  Count of number of adjustments (with different DCNs) of the claim that are 
included in the resolution file. 
Validation:  0 is used when only one DCN associated with the sampled claim is included 
in the resolution file. 
 
When the resolution file contains multiple adjustments associated with a 
single claim, this field will provide a count of records. 
 
  When the resolution file contains 2 DCNs related to a single 
claim, one of the records would contain a split/adjustment 
indicator of 1 and the second record would contain a 
split/adjustment indicator of 2. 
Remarks:  This indicator does not apply when multiple records are submitted for a single 
claim record because of size restrictions. 
 
CERT recognizes that Part A claims are not split. For Part A this field will 
identify adjustments only. 
Requirement:   Required when the resolution file contains multiple versions of a single 
claim. 
 
Data Element: Referring Physician NPI 
Definition:  NPI assigned to the Referring Physicianthe physician who requests an 
  item or service for the beneficiary for which payment may be made  
  under the Medicare program. 
Validation:  N/A 
Remarks:  Enter zeros if there is no referring physician  
Requirement:   Required when available on the claim record  
NOTES: 
  Referring physician - is a physician who requests an item or service for the 
beneficiary for which payment may be made under the Medicare program. 
  Ordering physician - is a physician or, when appropriate, a non- physician 
practitioner who orders non-physician services for the patient. 
 
Data Element: Referring Physician Last Name  
     
Definition:  Last name of the referring physician.  
Validation:  N/A 
Remarks:  Enter zeros if there is no referring/ordering provider  
Requirement: Required when available on the claim record. 
 
Data Element: Referring Physician Specialty 
Definition:  Code indicating the primary specialty of the referring physician.  
Validation:  N/A 
Remarks:  Enter zeros if the referring physician specialty is not available  
Requirement: Required when available on the claim record. 
 
Data Element: Claim Rendering Physician Specialty 
Definition:  Code indicating the primary specialty of the claim rendering physician.  
Validation:  N/A 
Remarks:  Enter zeros if the rendering physician specialty is not available  
Requirement: Required when available on the claim record. 
 
Data Element: Overpay Indicator 
Definition:  Code indicating whether or not an overpayment exists on an OIG or UPIC 
tracked adjustment claims. 
 
Validation: 
  Y indicates an overpayment exists on an OIG or UPIC claim 
  N indicates an overpayment does not exist on an 
OIG or UPIC claim. 
  Default value is blank for claims that are not OIG or UPIC tracked claims. 
Remarks:  This field is populated only when there is a value present in the FSSCIDRP- 
OVERPAY-CODE field 
Requirement:   Required when available on the claim record. 
 
Data Element: Overpay Code 
Definition:  Code that identifies an overpayment on an OIG or UPIC tracked adjustment 
claim.  
Validation:  Any of the user-defined values present in the online parm PRMOIGAA, 
PRMOIG00 through PRMOIG20 records. 
Remarks:  This field is populated only when the claim is an OIG or UPIC tracked 
adjustment claim. 
Requirement: Required when available on the claim record. 
 
Data Element: Claim Demonstration Identification Number 2  
Definition:  The number assigned to identify a demonstration project.  
Validation:  Must be numeric or zeroes 
Remarks:  This field contains the value from the second 
populated demonstration field. 
Requirement:   Required when available on the claim 
 
Data Element:  Claim Demonstration Identification Number 3  
Definition:  The number assigned to identify a demonstration project. 
Validation:  Must be numeric or zeroes 
Remarks:  This field contains the value from the third populated demonstration field.  
Requirement: Required when available on the claim 
 
Data Element:  Claim Demonstration Identification Number 4  
Definition:  The number assigned to identify a demonstration project. 
Validation:  Must be numeric or zeroes. 
     
Remarks:  This field contains the value from the fourth populated demonstration field.  
Requirement: Required when available on the claim. 
 
Data Element:  Beneficiary MBI 
Definition:  Beneficiarys Medicare Beneficiary Identifier  
Validation:  Comply with CMS Standards 
  11-character, fixed length alpha-numeric string 
  Different, visibly distinguishable from HICN/RRB numbers 
  Contain no more than 2 consecutive numbers 
  Contain no more than 2 consecutive alphabetic characters 
  Must limit the possibility of letters being interpreted as numbers (i.e., 
alphabetic characters [A...Z]; excluding S, L, O, I, B, Z) 
  Must not contain lowercase letters 
  Must not contain any special characters  
Remarks:  Do not include hyphens or spaces  
Requirement:  Required 
 
Data Element: HICN/MBI Indicator 
Definition:  Indicator that identifies if the provider submitted the claim with a HICN or 
MBI  
Validation: 
M = MBI submitted on the claim  
H = HICN submitted on the claim 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Filler 
Definition:  Additional space -- use to be determined  
Validation:  N/A 
Remarks:  N/A  
Requirement: Required 
 
Data Element:   Total Line Item Count 
Definition:  Number indicating number of service lines on the claim  
Validation:  Must be a number 001 - 450 
Remarks:  N/A  
Requirement: Required 
 
Data Element:   Record Line Item Count 
Definition:  Number indicating number of service lines on this record  
Validation:  Must be a number 001 - 100 
Remarks:  N/A  
Requirement: Required 
 
Claim Line Item Fields 
 
Data Element:   Revenue Center Code 
Definition:  Code assigned to each cost center for which a charge is billed.  
Validation:  Must be a valid NUBC-approved code. 
Must be a valid code as listed in Pub 100-4, Medicare Claims Processing 
Manual, Chapter 25, Completing and Processing CMS-1450 Data Set. 
Remarks:  Include an entry for revenue code 0001  
Requirement: Required 
 
     
Data Element: NF-RUG-III Code 
Definition:  Skilled Nursing Facility Resource Utilization Group Version III (RUG-III) 
descriptor. This is the rate code/assessment type that identifies (1) RUG-III 
group the beneficiary was classified into as of the Minimum Data Set (MDS) 
assessment reference date and (2) the type of assessment for payment 
purposes. 
Validation:  N/A 
Remarks:  N/A 
Requirement: Required for SNF inpatient bills 
 
Data Element: APC Adjustment Code 
Definition:  The Ambulatory Payment Classification (APC) Code or Home Health 
Prospective Payment System (HIPPS) code. The APC codes are the basis for 
the calculation of payment of services made for hospital outpatient services, 
certain PTB services furnished to inpatients who have no Part A coverage, 
CMHCs, and limited services provided by CORFs, Home Health Agencies or to 
hospice patients for the treatment of a non-terminal illness. 
 
This field may contain a HIPPS code. If a HHPPS HIPPS code is down coded, 
the down coded HIPPS will be reported in this field. 
 
The HIPPS code identifies (1) the three case-mix dimensions of the Home 
Health Resource Group (HHRG) system, clinical, functional and utilization, 
from which a beneficiary is assigned to one of the 80 HHRG categories and 
(2) it identifies whether or not the elements of the code were computed or 
derived. The HHRGs, represented by the HIPPS coding, is the basis of 
payment for each episode. 
Validation:  N/A 
Remarks:  Left justify the APC Adjustment Code  
Requirement:   Required if present on claim record 
 
Data Element: HCPCS Procedure Code or HIPPS Code 
Definition:  The HCPCS/CPT-4 code that describes the service or Health Insurance PPS 
(HIPPS) code. 
Validation:  Must be a valid HCPCS/CPT-4 or HIPPS code 
Remarks:  Healthcare Common Procedure Coding System (HCPCS) is a collection of 
codes that represent procedures, supplies, products and services which may 
be provided to Medicare beneficiaries and to individuals enrolled in private 
health insurance programs 
 
When revenue center code = '0022' (SNF PPS), '0023' (HH PPS), or '0024' 
(IRF 
PPS); this field contains the Health Insurance PPS (HIPPS) code. 
 
The HIPPS code for SNF PPS contains the rate code/assessment type that 
identifies RUG-III group the beneficiary was classified into as of the RAI MDS 
assessment reference date and (2) the type of assessment for payment 
purposes. 
 
The HIPPS code for Home Health PPS identifies (1) the three case-mix 
dimensions of the HHRG system, clinical, functional and utilization, from 
which a beneficiary is assigned to one of the 80 HHRG categories and (2) it 
identifies whether or not the elements of the code were computed or derived. 
The HHRGs, represented by the HIPPS coding, will be the basis of payment 
for each episode. 
 
     
The HIPPS code (CMG Code) for IRF PPS identifies the clinical characteristics 
of the beneficiary. The HIPPS rate/CMG code (AXXYY - DXXYY) must contain 
five digits. The first position of the code is an A, B, C, or 'D'.  The HIPPS code 
beginning with an 'A' in front of the CMG is defined as without co-morbidity. 
The 'B' in front of the CMG is defined as with co-morbidity for Tier 1. The 'C' is 
defined as co-morbidity for Tier 2 and 'D' is defined as co-morbidity for Tier 3. 
The 'XX' in the HIPPS rate code is the Rehabilitation Impairment Code (RIC). 
The 'YY' is the sequential number system within the RIC. 
Requirement:   Required if present on claim record 
 
Data Element:  HCPCS Modifier 1 
HCPCS Modifier 2 
HCPCS Modifier 3 
HCPCS Modifier 4 
HCPCS Modifier 5 
Definition:  Codes identifying special circumstances related to the service  
Validation:  N/A 
Remarks:  N/A 
Requirement: Required if available 
 
Data Element:   Line Item Date 
Definition:  The date the service was initiated  
Validation:  Must be a valid date. 
Remarks:  Format is CCYYMMDD 
Requirement: Required if on bill and included in the shared system 
 
Data Element: Line Submitted Charge 
Definition:  Actual charge submitted by the provider or supplier for the service or 
equipment  
Validation:  N/A 
Remarks:  This is a required field. CR3997 provided direction on how to populate this 
field if data is not available in the claim record. 
Requirement: Required 
 
Data Element: Line Medicare Initial Allowed Charge 
Definition:  Amount Medicare allowed for the service or equipment before any reduction or 
denial. 
Validation:  Must be a numeric value. 
Remarks:  This is a required field. Use the value in FISS field FSSCPDCL-REV-COV-CHRG- 
AMT to populate this field (per CMS Change Request 3912). 
Requirement: Required 
 
Data Element:  ANSI Reason Code 1-14 
Definition:  Codes showing the reason for any adjustments to this line, such as denials or 
reductions of payment from the amount billed. 
Validation:  Must be valid ANSI ASC claim adjustment codes and applicable group codes. 
Remarks:  Format is GGRRRRRR where: G is the group code and RRRRRR is the 
adjustment reason code. 
Requirement: Report all ANSI Reason Codes included on the bill. 
 
Data Element: Manual Medical Review Indicator 
Definition:  Code indicating whether or not the service received complex manual medical 
review.  Complex review goes beyond routine review. It includes the request 
for, collection of, and evaluation of medical records or any other 
documentation in addition to the documentation on the claim, attached to the 
claim, or contained in the MACs history file. The review must require 
     
professional medical expertise and must be for the purpose of preventing 
payments of non-covered or incorrectly coded services.  That includes reviews 
for the purpose of determining if services were medically necessary. 
Professionals must perform the review, i.e., at a minimum, a Licensed 
Practical Nurse must perform the review.  Review requiring use of the MAC's 
history file does not make the review a complex review. A review is not 
considered complex if a medical record is requested from a provider and not 
received. If sufficient documentation accompanies a claim to allow complex 
review to be done without requesting additional documentation, count the 
review as complex. For instance if all relative pages from the patient's 
medical record are submitted with the claim, complex MR could be conducted 
without requesting additional documentation. 
Validation:  Must be Y or N 
Remarks:  Set to Y if service was subjected to complex manual medical review, else N.  
Requirement: Required 
 
Data Element: Resolution Code 
Definition:  Code indicating how the MAC resolved the line. 
 
Automated Review (AM): An automated review occurs when a claim/line item 
passes through the MAC's claims processing system or any adjunct system 
containing medical review edits. 
 
Routine Manual Review (MR): Routine review uses human intervention, but 
only to the extent that the claim reviewer reviews a claim or any attachment 
submitted by the provider. It includes review that involves review of any of 
the MAC's internal documentation, such as claims history file or policy 
documentation. It does not include review that involves review of medical 
records or other documentation requested from a provider. A review is 
considered routine if a medical record is requested from a provider and not 
received. Include prior authorization reviews in this category. 
 
Complex Manual Review (MC): Complex review goes beyond routine review. 
It includes the request for, collection of, and evaluation of medical records or 
any other documentation in addition to the documentation on the claim, 
attached to the claim, or contained in the MACs history file. The review must 
require professional medical expertise and must be for the purpose of 
preventing payments of non- covered or incorrectly coded services. 
Professionals must perform the review, i.e., at a minimum; a Licensed 
Practical Nurse must perform the review. Review requiring use of the MAC's 
history file does not make the review a complex review. A review is not 
considered complex if a medical record is requested from a provider and not 
received. If sufficient documentation accompanies a claim to allow complex 
review to be done without requesting additional documentation, the review is 
complex. For instance if all relevant pages from the patient's medical record 
are submitted with the claim, complex MR could be conducted without 
requesting additional documentation. 
 
Validation:  Must be APP, APPMR, APPMC, DENMR, DENMC, DEO, RTP, 
REDMR, REDMC, REO, DENAM, REDAM,INACT. 
Remarks: 
Resolution Code  Description 
APP  Approved as a valid submission without 
manual medical review. 
     
APPAM  Approved after automated medical review 
APPMR  Approved after manual medical review routine 
APPMC  Approved after manual medical review complex. If 
this code is selected, set the Manual Medial 
Review Indicator to 'Y. 
DENAM  Denied after automated medical review 
DENMR  Denied for medical review reasons or for 
insufficient documentation of medical necessity, 
manual medical review routine 
DENMC  Denied for medical review reasons or for 
insufficient documentation medical necessity, 
manual medical review complex. If this codes 
is selected, set the Manual Medial Review 
Indicator to 'Y.' 
DEO  Denied for non-medical reasons, other 
than denied as unprocessable. 
RTP  Denied as unprocessable (return/reject) 
REDAM  Reduced after medical review 
REDMR  Reduced for medical review reasons or for 
insufficient 
documentation of medical necessity, manual 
medical review routine 
REDMC  Reduced for medical review reasons or for 
insufficient documentation of medical necessity, 
manual medical review complex. If this code is 
selected, set the Manual Medial 
Review Indicator to 'Y.' 
REO  Reduced for non-medical review reasons. 
INACT  Claim is inactive as identified by I Status 
 
Requirement: Required 
 
Data Element: Final Allowed Charge 
Definition:  Final amount paid to the provider for this service or equipment plus patient 
responsibility. 
Validation:  N/A  
Remarks:  N/A  
Requirement:   Required 
 
Data Element:  Cash Deductible 
Definition:  The amount of cash deductible the beneficiary paid for the line item service.  
Validation:  N/A 
Remarks:  N/A  
Requirement:   Required 
 
Data Element: Special Action/Override Code 
Definition:  Code used to identify special actions taken in determining payment of this line 
item.  
Validation:  Must be valid 
Remarks:  N/A  
Requirement:   Required 
     
 
Data Element: Units 
Definition:  The total number of services or time periods provided for the line item. 
Validation:  N/A 
Remarks:  Zero filled to maintain the relative position of the decimal point.  The last 
three positions should contain the value to the right of the decimal in the 
number of services. Put a zero in the last three positions for whole numbers. 
For example if the number of units is 10, this field would be filled as 
0000010000. 
Requirement:   Required 
 
Data Element:   Rendering Physician NPI 
Definition:  NPI assigned to the Rendering Physician.  
Validation:  N/A 
Remarks:  Left justify 
Requirement: Required when available on claim record. 
 
Data Element: Rendering Physician Last Name 
Definition:  Last Name (Surname) of the rendering physician.  
Validation:  Must be present 
Remarks:  N/A 
Requirement: Required when available on claim record 
 
Data Element: National Drug Code (NDC) field  
Definition:  To be assigned at a later date. 
Validation:  N/A 
Remarks:  Left justify 
Requirement: Required when available on claim record. 
 
Data Element: National Drug Code (NDC) Quantity Qualifier  
Definition:  To be assigned at a later date. 
Validation:  Must be present.  
Remarks:  N/A 
Requirement: Required when available on claim record. 
 
Data Element: National Drug Code (NDC) Quantity  
Definition:  To be assigned at a later date. 
Validation:  Must be present. 
Remarks:  Zero filled to maintain the relative position of the decimal point. 
For example, if the number of units is 10, this field would be filled as 
0000010000. 
Requirement: Required when available on claim record. 
 
Data Element: PWK Filler 
Definition:  PWK space -- use to be determined.  
Validation:  N/A 
Remarks:  N/A 
Requirement: Required when available on claim 
 
Data Element:   Rendering Physician Specialty 
Definition:  Code indicating the primary specialty of the rendering physician.  
Validation:  N/A 
Remarks:  Enter zeros if the rendering physician specialty is not available  
Requirement: Required when available on the claim record. 
 
Data Element: Prior Authorization Program Indicator 
     
Definition:  Prior Authorization Program Indicator issued by CMS to identify to which PA 
program the service belongs 
Validation:   Four character alphanumeric 
 The first character identifies the line of business 
  A for Part A, 
  B for Part B, 
  D for DME, 
  H for Home Health and Hospice 
 Followed by a three digit number. 
Remarks:  N/A 
Requirement:   Required for claims containing services subject to a prior authorization 
program. 
 
Data Element: Unique Tracking Number (UTN) 
Definition:  Unique Tracking Number (UTN) assigned to the prior authorization request for 
the service or item. 
Validation:  UTN shall be 14 characters and use the following format: 
  First two characters = MAC identifier (e.g., RR for Railroad, 0F for Jurisdiction 
F, 05 for Jurisdiction 5, etc.). 
  Third character = line of business (e.g., A for Part A, B for Part  
B, D for DME, H for Home Health and Hospice). 
  Remaining numerical characters = a unique sequence number assigned by 
the Shared System. 
Remarks:  N/A 
Requirement:   Required for claims containing services covered by an affirmed prior 
authorization. 
 
Data Element:   Prior Auth Affirmed 
Definition:  Code to identify if the prior authorization for the service(s) on this line was 
affirmed.  
Validation: 
  Y indicates the prior authorization was affirmed. 
  N indicates the prior authorization was not affirmed. 
  Default value is blank for claims that are not part of prior authorization 
demonstration. 
Remarks:  N/A 
Requirement: Required for claims containing services subject to prior authorization in the 
state  
where the service was furnished. 
 
Data Element: Filler 
Definition:  Additional space -- use to be determined  
Validation:  N/A 
Remarks:  N/A  
Requirement: Required 
 
Claims Resolution File 
Claims Resolution Trailer Record (one record per file) 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
     
Record Type  X(1)  6  6  3   
Record Version Code  X(1)  7  7  Spaces   
Contractor Type  X(1)  8  8  Spaces   
Number of Claims  9(9)  9  17  Zeroes   
 
 
 
 
DATA ELEMENT DETAIL 
 
Data Element:   Contractor ID 
Definition:   Contractors CMS assigned number.  
Validation:   Must be a valid CMS contractor ID.  
Remarks:   N/A 
Requirement:   Required 
NOTE:  For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor 
ID specified by CMS. 
 
Data Element:   Record Type 
Definition:  Code indicating type of record.  
Validation:  N/A 
Remarks:  3 = Trailer Record  
Requirement: Required 
 
Data Element: Record Version Code 
Definition:  The code indicating the record version of the Claim Resolution file.  
Validation:  Claim Resolution files prior to 10/1/2007 did not contain this field. 
Codes: 
B = Record Format as of 10/1/2007  
C = Record Format as of 1/1/2010  
D = Record Format as of 10/1/2012  
E = Record Format as of 7/1/2016  
F = Record Format as of 10/1/2017 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor included in the file  
Validation:  Must be A or R. 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
Remarks:  A = A/B MAC (A) only 
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)  
Requirement: Required 
 
Data Element:   Number of Claims 
Definition:  Number of claim records on this file 
Validation:  Must be equal to the number of claim records on the file  
Remarks:  Do not count header or trailer records 
Requirement:   Required 
 
Claims Provider Address File 
     
Claims Provider Address Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  1 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Provider Address Date  X(8)  9  16  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:   Contractors CMS assigned number  
Validation:   Must be a valid CMS contractor ID  
Remarks:   N/A 
Requirement:   Required 
NOTE:  For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor 
ID specified by CMS 
 
Data Element: Record Type 
Definition:  Code indicating type of record  
Validation:  N/A 
Remarks:  1 = Header record  
Requirement: Required 
 
Data Element: Record Version Code 
Definition:  The code indicating the record version of the Claim Provider Address file  
Validation:  Claim Provider Address files prior to 10/1/2007 did not contain this field. 
Codes: 
B = Record Format as of 10/1/2007  
C = Record Format as of 1/1/2010  
D = Record Format as of 10/1/2012  
E = Record Format as of 7/1/2016 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor included in the file  
Validation:  Must be A or R 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R.  
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
Remarks:  A = A/B MAC (A) only 
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)  
Requirement: Required 
 
Data Element:   Provider Address Date 
Definition:  Date the Provider Address File was created. 
Validation:  Must be a valid date not equal to a Provider Address date 
sent on any previous claims Provider Address file 
Remarks:  Format is CCYYMMDD. May use shared system batch processing date  
Requirement: Required 
 
     
Provider Address File 
Provider Address Detail Record 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  Spaces 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Sequence Number  X(1)  9  9  Spaces 
Provider Number  X(15)  10  24  Spaces 
Provider Name  X(60)  25  84  Spaces 
Provider Address 1  X(25)  85  109  Spaces 
Provider Address 2  X(25)  110  134  Spaces 
Provider City  X(15)  135  149  Spaces 
Provider State Code  X(2)  150  151  Spaces 
Provider Zip Code  X(9)  152  160  Spaces 
Provider Phone Number  X(10)  161  170  Spaces 
Provider Phone Number Extension  X(10)  171  180  Spaces 
Provider FAX Number  X(10)  181  190  Spaces 
Provider Type  X(1)  191  191  Spaces 
Provider Address Type  9(3)  192  194  1 
Provider E-mail Address  X(75)  195  269  Spaces 
Provider Federal Tax number or EIN  9(10)  270  279  Zeroes 
Filler  X(16)  280  295  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:   Contractors CMS assigned number  
Validation:   Must be a valid CMS contractor ID  
Remarks:   N/A 
Requirement:   Required 
NOTE:  For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor ID 
specified by CMS 
 
Data Element: Record Type 
Definition:  Code indicating type of record  
Validation:  N/A 
Remarks:  2 = Detail record  
Requirement: Required 
 
Data Element: Record Version Code 
Definition:  The code indicating the record version of the Claim Provider Address file  
Validation:  Claim Provider Address files prior to 10/1/2007 did not contain this field. 
Codes: 
B = Record Format as of 10/1/2007  
C = Record Format as of 1/1/2010  
D = Record Format as of 10/1/2012  
E = Record Format as of 10/1/2017 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Contractor Type 
     
Definition:  Type of Medicare Contractor included in the file  
Validation:  Must be A or R. 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
 
Data Element: Sequence Number 
Definition:  Number occurrence number of addresses when there are multiple addresses 
for a provider. 
Validation:  Must be between 1 and 3 
Remarks:  Enter 1 if there is only one address for a provider  
Requirement: Required 
 
Data Element: Provider Number 
Definition:  Number assigned by Medicare to identify the provider  
Validation:  N/A 
Remarks:  Left justify  
Requirement: Required 
 
Data Element: Provider Name  
Definition:  Provider's name  
Validation:  N/A 
Remarks:  This is the business name associated with the provider number. Must be 
formatted into a name for mailing (e. g., Roger A Smith M.D. or Medical 
Associates, Inc.) 
Requirement: Required 
 
Data Element:  Provider Address 1  
Definition:  First line of provider's address  
Validation:  N/A 
Remarks:  This is the first line of the address associated with the provider number 
indicated in the record. 
Requirement: Required for all Billing Provider Numbers. Furnish as available 
for other types of provider numbers. 
 
Data Element: Provider Address 2 
Definition:  Second line of providers address  
Validation:  N/A 
Remarks:  This is the line of the address associated with the provider number indicated 
in the record. 
Requirement: Required for all Billing Provider Numbers. Furnish as available for other types 
of provider numbers. 
 
Data Element: Provider City  
Definition:  Providers city name  
Validation:  N/A 
Remarks:  This is the city of the provider number 
Requirement: Required for Billing Provider Numbers. Furnish as available for other types of 
provider numbers. 
 
Data Element: Provider State Code  
Definition:  Provider's state code  
Validation:  Must be a valid state code 
Remarks:  This is the state associated with the address of the provider number. 
     
Requirement: Required for Billing Provider Numbers. Furnish as available for other types of 
provider numbers. 
 
Data Element: Provider Zip Code  
Definition:  Provider's zip code 
Validation:  Must be a valid postal zip code 
Remarks:  This is the zip code associated with the address furnished for the provider 
number identified in this record. 
  Provide 9-digit zip code if available, otherwise provide 5-digit zip code. 
Requirement: Required for Billing Provider Numbers. Furnish as available for other types of 
provider numbers. 
 
Data Element: Provider Phone Number  
Definition:  Provider's phone number  
Validation:  Must be a valid phone number  
Remarks:  N/A 
Requirement: Required if available 
 
Data Element: Provider Phone Number Extension  
Definition:  Provider's phone number extension  
Validation:  Must be a valid phone number  
Remarks:  N/A 
Requirement: Required if available 
 
Data Element: Provider Fax Number  
Definition:  Providers fax number  
Validation:  Must be a valid fax number  
Remarks:  N/A 
Requirement: Required if available  
 
Data Element: Provider Type 
Definition:  1=Billing Provider Number (OSCAR)  
  2=Attending Physician Number (UPIN)  
  3=Operating Physician Number (UPIN)  
  4=Other Physician Number (UPIN)  
  5=Billing Provider NPI 
6=Attending Physician NPI  
7=Operating Physician NPI  
8=Rendering Physician NPI 
Validation:  Must be 1-8. 
Remarks:  This field identifies the type of provider number whose name, address, phone 
number and identification information are included in the record. 
Requirement: Required 
 
Data Element: Provider Address Type 
Definition:  The type of Provider Address furnished.  
Validation:  1 = Master Address (FISS) 
2 = Remittance Address (FISS) 
3 = Check Address (FISS) (APASS)  
4 = MSP Other Address (FISS) 
5 = Medical Review Address (FISS) (APASS)  
6 = Other Address (FISS) (APASS) 
7 = Chain Address (APASS)  
8 = Correspondence Address  
9 = Medical Record Address 
 
     
Remarks:  The first address type for each provider will always be a 1. 
Subsequent occurrences of addresses for the same provider will have the 
address type to correspond to the address submitted.  When your files 
contain only one address for the provider, submit only one provider address 
record. Submit additional address records for a single provider number only 
when your files contain addresses that differ from the Master or Legal 
address. 
 
  Correspondence AddressThe Correspondence Address as indicated on the 
855A. This is the address and telephone number where Medicare can directly 
get in touch with the enrolling provider. This address cannot be that of the 
billing agency, management service organization, or staffing company. 
  Medical Record Addressthe Location of Patients Medical Records as 
indicated on the 855A. This information is required if the Patients Medical 
Records are stored at a location other than the Master Address (practice 
location). Post Office Boxes and Drop Boxes are not acceptable as the 
physical address where patients medical records are maintained. 
Requirement:   Required Billing Provider Numbers. Furnish as available for 
other types of provider numbers. 
 
Data Element: Provider E-Mail Address  
Definition:  Providers e-mail address.  
Validation:  Must be a valid e-mail address.  
Remarks:  N/A 
Requirement: Required if available. 
 
Data Element: Provider Federal Tax Number or EIN 
Definition:  The number assigned to the billing provider by the Federal government for 
tax report purposes. The Federal Tax Number is also known as a tax 
identification number (TIN) or employer identification number (EIN). 
Validation:  Must be present  
Remarks:  N/A 
Requirement: Required for all Billing Provider Numbers. For all other types of provider  
numbers, the tax number is required when available 
 
Data Element: Filler 
Definition:  Additional space -- use to be determined  
Validation:  N/A 
Remarks:  N/A  
Requirement: Required 
 
Claims Provider Address File 
Claims Provider Address Trailer Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  3 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Number of Records  9(9)  9  17  Zeroes 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
     
Definition:   Contractors CMS assigned number.  
Validation:   Must be a valid CMS contractor ID.  
Remarks:   N/A 
Requirement:   Required 
NOTE:  For A/B MAC (A) and A/B MAC (HHH), when multiple workloads share a single 
processing environment, the Contractor ID will reflect the roll-up Contractor 
ID specified by CMS. 
 
Data Element: Record Type 
Definition:  Code indicating type of record  
Validation:  N/A 
Remarks:  3 = Trailer Record  
Requirement: Required 
 
Data Element: Record Version Code 
Definition:  The code indicating the record version of the Claim Universe file  
Validation:  Claim Universe files prior to 10/1/2007 did not contain this field. 
Codes: 
B = Record Format as of 10/1/2007  
C = Record Format as of 1/1/2010  
D = Record Format as of 10/1/2012  
E = Record Format as of 10/1/2017 
Remarks:  N/A  
Requirement: Required 
 
Data Element: Contractor Type 
Definition:  Type of Medicare Contractor included in the file  
Validation:  Must be A or R 
st 
Where the TYPE of BILL, 1 position = 3, Contractor Type should be R. 
st nd 
Where the TYPE of BILL, 1 /2 positions = 81 or 82, contractor Type should 
be R. 
All others will be contractor type A. 
Remarks:  A = A/B MAC (A) only 
R = A/B MAC (HHH) only or both A/B MAC (A) and A/B MAC (HHH)  
Requirement: Required 
 
Data Element: Number of Records 
Definition:  Number of provider address records on this file 
Validation:  Must be equal to the number of provider address records on the file  
Remarks:  Do not count header or trailer records 
Requirement: Required 
 
 
Exhibit 36.2 
(Rev. 726, Issued: 06-16-17, Effective: 10-01-17, Implementation: 01-02-18 - For VMS and 
MCS for Business Requirements 11 through 22 and 22.1; 10-02-17 - For FISS) 
 
Claims Universe File 
Claims Universe Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  1 
Record Version Code  X(1)  7  7  Spaces 
     
Contractor Type  X(1)  8  8  Spaces 
Universe Date  X(8)  9  16  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element:   Contractor ID 
Definition:          Contractors CMS assigned number.  
Validation:          Must be a valid CMS contractor ID.  
Remarks:      N/A 
Requirement:      Required 
NOTE:       For A/B MAC (B): when multiple workloads share a single 
    processing environment, the Contractor ID will reflect the contractor  
    ID of the primary workload. 
 
 
Data Element:  Record Type 
Definition:    Code indicating type of record.  
Validation:    N/A 
Remarks:    1 = Header record  
Requirement:    Required 
 
Data Element: Record Version Code 
Definition:    The code indicating the record version of the Claim Universe file.  
Validation:    Claim Universe files prior to 7/1/2007 did not contain this field. 
      Codes: 
      B = Record Format as of 7/1/2007 
      C = Record Format as of 10/1/2017 
Remarks:    N/A  
Requirement:    Required 
 
Data Element:  Contractor Type  
Definition:    Type of Medicare Contractor  
Validation:    Must be B or D 
Remarks:    B = A/B MAC (B) 
       D = DME MAC 
Requirement:    Required 
 
Data Element:  Universe Date 
Definition:    Date the universe of claims entered the shared system. 
Validation:    Must be a valid date not equal to a universe date sent on any previous 
  claims universe file. 
Remarks:    Format is CCYYMMDD. 
    Shared System logic may use shared system batch processing date as long as 
the date is not equal to the universe date sent on any previous claims universe 
file. 
Requirement:    Required 
 
Claims Universe File 
Claims Universe Claim Detail Record 
     
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  "2" 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Claim Control Number  X(15)  9  23  Spaces 
Beneficiary HICN  X(12)  24  35  Spaces 
Billing Provider NPI  X(10)  36  45  Spaces 
Claim Submitted Charge Amount  S9(7)v99  46  54  Zeroes 
Claim Demonstration Number  X(2)  55  56  Spaces 
Claim State  X(2)  57  58  Spaces 
Beneficiary State  X(2)  59  60  Spaces 
Billing Provider Specialty  X(2)  61  62  Spaces 
Beneficiary MBI  X(11)  63  73  Spaces 
HICN/MBI Indicator  X(1)  74  74  Spaces 
Filler  X(3)  75  77  Spaces 
Line Item Count  9(2)  78  79  Zeroes 
 
Claims Universe File 
Claims Universe Claim Line Item Detail Record 
*Line Item group: The following group of Fields occurs from 1 to 52 Times (depending on Line 
Item Count). 
*From and Thru values relate to the 1st line item 
 
Field Name  Picture  From  Thru  Initialization 
Performing Provider Number  X(15)  80  94  Spaces 
Performing Provider Specialty  X(2)  95  96  Spaces 
HCPCS Procedure Code  X(5)  97  101  Spaces 
From Date of Service  X(8)  102  109  Spaces 
To Date of Service  X(8)  110  117  Spaces 
Line Submitted Charge  S9(7)v99  118  126  Zeroes 
Performing Provider NPI  X(10)  127  136  Spaces 
 
DATA ELEMENT DETAIL 
 
Claim Header Fields 
 
Data Element:  Contractor ID 
Definition:          Contractors CMS assigned number  
Validation:          Must be a valid CMS contractor ID  
Remarks:      N/A 
Requirement:      Required 
NOTE:       For A/B MAC (B): when multiple workloads share a single  
processing environment, the Contractor ID will reflect the contractor 
ID of the primary workload. 
 
Data Element:  Record Type 
Definition:    Code indicating type of record  
Validation:    N/A 
     
Remarks:    2 = claim record  
Requirement:    Required 
Data Element:  Record Version Code 
Definition:    The code indicating the record version of the Claim Universe file  
Validation:    Claim Universe files prior to 7/1/2007 did not contain this field. 
      Codes: 
      B = Record Format as of 7/1/2007 
      C = Record Format as of 10/1/2017 
Remarks:    N/A  
Requirement:    Required 
 
Data Element:  Contractor Type  
Definition:    Type of Medicare Contractor  
Validation:    Must be B or D 
Remarks:    B = A/B MAC (B) 
      D = DME MAC 
Requirement:    Required 
 
Data Element:  Claim Control Number 
Definition:    Number assigned by the shared system to uniquely identify the claim.  
Validation:    The required format for the Claim Control Number is different for each 
       claim type. 
    DME:  must be 15 digits with a leading 1 as filler. 
    Part B:  must be 15 digits, with two leading zeros as filler. 
Remarks:    N/A  
Requirement:    Required 
 
Data Element:  Beneficiary HICN 
Definition:    Beneficiarys Health Insurance Claim Number.  
Validation:    N/A 
Remarks:    N/A  
Requirement:    Required 
 
Data Element:  Billing Provider NPI 
Definition:    NPI assigned to the Billing Provider.  
Validation:    N/A 
Remarks:    N/A.  
Requirement:    Required. 
 
Data Element:  Claim Submitted Charge Amount 
Definition:    The total submitted charges on the claim (the sum of line item 
   submitted charges). 
Validation:    N/A 
Remarks:    N/A 
Requirement:    Required 
 
Data Element:  Claim Demonstration Number 
     
Definition:  Also known as Claim Demonstration Identification Number. The number 
assigned to identify a demonstration Project.  This field is also used to denote 
special processing (a.k.a. Special Processing Number, SPN). 
Validation:  Must be a Valid Demo ID. 
Remarks:  N/A 
Requirement:  Required when available on claim. 
 
Data Element:  Claim State 
Definition:  State abbreviation identifying the state in which the service is furnished.  
Validation:  Must be a valid 2 digit state abbreviation as defined by the United States  
  Postal Service (USPS). 
Remarks:  When services on a single claim are furnished in multiple states, enter the state 
identifier for the first detail line. 
Requirement:  Required for all Part B Claims.  For DME claims, required if available. 
 
Data Element:  Beneficiary State 
Definition:  State abbreviation identifying the state in which the beneficiary resides.  
Validation:  Must be a valid 2 digit state abbreviation as defined by the United States  
  Postal Service (USPS). 
Remarks:  N/A 
Requirement:  Required, when available. 
 
Data Element:  Billing Provider Specialty 
Definition:  Code indicating the primary specialty of the Billing provider or supplier.  
Validation:  N/A 
Remarks:  N/A  
Requirement:  Required 
 
Data Element: Beneficiary MBI 
Definition:  Beneficiarys Medicare Beneficiary Identifier  
Validation:  Comply with CMS Standards 
  11-character, fixed length alpha-numeric string. 
  Different, visibly distinguishable from HICN/RRB numbers. 
               Contain no more than 2 consecutive numbers. 
    Contain no more than 2 consecutive alphabetic characters. 
    Must limit the possibility of letters being interpreted as 
numbers (i.e., alphabetic characters [A...Z]; excluding S, L, O, I, B, Z). 
              Must not contain lowercase letters. 
              Must not contain any special characters.  
Remarks:    Do not include hyphens or spaces.  
Requirement:     Required 
 
Data Element:  HICN/MBI Indicator 
Definition:   Indicator that identifies if the provider submitted the claim with a HICN or MBI.  
Validation: 
    M = MBI submitted on the claim  
    H = HICN submitted on the claim 
Remarks:  N/A  
Requirement:  Required 
     
 
Data Element: Filler 
Definition:  Additional space -- use to be determined  
Validation:  N/A 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  Line Item Count 
Definition:  Number indicating number of service lines on the claim.  
Validation:  Must be a number 01  52. 
Remarks:  N/A  
Requirement:  Required 
 
Claim Line Item Fields 
 
Data Element:  Performing Provider Number 
Definition:  Number assigned by the NSC or MAC to identify the provider who performed the 
service or the supplier who supplied the medical equipment. 
Validation:  N/A 
Remarks:  Enter the PIN of the performing provider.  When several different   
  providers of service or suppliers are billing on the same claim, show the  
  individual PIN in the corresponding line item. 
Requirement:  Required 
 
Data Element: Performing Provider Specialty 
Definition:  Code indicating the primary specialty of the performing provider or  
  supplier.  
Validation:  N/A 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  HCPCS Procedure Code 
Definition:  The HCPCS/CPT-4 code that describes the service.  
Validation:  N/A 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  From Date of Service 
Definition:  The date the service was initiated. 
Validation:  Must be a valid date less than or equal to To Date of Service. 
Remarks:  Format is CCYYMMDD 
Requirement:  Required 
 
Data Element:  To Date of Service 
Definition:  The date the service ended. 
Validation:  Must be a valid date greater than or equal to From Date of Service.  
Remarks:  Format is CCYYMMDD 
Requirement:  Required 
 
     
Data Element:  Line Submitted Charge 
Definition:  Actual charge submitted by the provider or supplier for the service or  
  equipment.  
Validation:  N/A 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  Performing Provider NPI 
Definition:  NPI assigned to the Performing Provider.  
Validation:  N/A 
Remarks:  N/A.  
Requirement:  Required 
 
Claims Universe File 
Claims Universe Trailer Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  3 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Number of Claims  9(9)  9  17  Zeroes 
 
DATA ELEMENT DETAIL 
 
Data Element:  Contractor ID 
Definition:        Contractors CMS assigned number.  
Validation:        Must be a valid CMS contractor ID.  
Remarks:    N/A 
Requirement:    Required 
NOTE:     For A/B MAC (B): when multiple workloads share a single processing  
      environment, the Contractor ID will reflect the contractor ID of the 
  primary workload. 
 
Data Element:  Record Type 
Definition:    Code indicating type of record  
Validation:    N/A 
Remarks:    3 = Trailer Record  
Requirement:    Required 
 
Data Element:  Record Version Code 
Definition:    The code indicating the record version of the Claim Universe file  
Validation:    Claim Universe files prior to 7/1/2007 did not contain this field. 
      Codes: 
      B = Record Format as of 7/1/2007 
      C = Record Format as of 10/1/2017 
Remarks:    N/A  
Requirement:    Required 
 
Data Element:  Contractor Type  
     
Definition:    Type of Medicare Contractor  
Validation:    Must be B or D 
Remarks:    B = A/B MAC (B) 
      D = DME MAC 
Requirement:    Required 
 
Data Element:  Number of Claims 
Definition:    Number of claim records on this file 
Validation:    Must be equal to the number of claim records on the file  
Remarks:    Do not count header or trailer records 
Requirement:    Required 
 
Claims Transaction File 
Claims Transaction Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  1 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Transaction Date  X(8)  9  16  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element:  Contractor ID 
Definition:        Contractors CMS assigned number  
Validation:        Must be a valid CMS contractor ID  
Remarks:    N/A 
Requirement:    Required 
NOTE:     For A/B MAC (B): when multiple workloads share a single processing  
      environment, the Contractor ID will reflect the contractor ID of the       
primary workload. 
 
Data Element:  Record Type 
Definition:    Code indicating type of record  
Validation:    N/A 
Remarks:    1 = Header record  
Requirement:    Required 
 
Data Element:  Record Version Code 
Definition:    The code indicating the record version of the Claim Transaction file  
Validation:    Claim Transaction files prior to 7/1/2007 did not contain this field. 
      Codes: 
      B = Record Format as of 7/1/2007 
Remarks:    N/A  
Requirement:    Required 
 
Data Element:  Contractor Type  
Definition:    Type of Medicare Contractor  
Validation:    Must be B or D 
     
Remarks:    B = A/B MAC (B) 
      D = DME MAC 
Requirement:    Required 
 
Data Element:  Transaction Date 
Definition:    Date the Transaction File was created 
Validation:  Must be a valid date not equal to a Transaction date sent on any previous  claims 
Transaction file. 
Remarks:   Format is CCYYMMDD. May use shared system batch processing date.  
Requirement:    Required 
 
Sampled Claims Transaction File 
Sampled Claims Transaction File Detail Record 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  2 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Claim Control Number  X(15)  9  23  Spaces 
Beneficiary HICN  X(12)  24  35  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element:  Contractor ID 
Definition:         Contractors CMS assigned number.  
Validation:        Must be a valid CMS contractor ID.  
Remarks:    N/A 
Requirement:    Required 
NOTE:     For A/B MAC (B): when multiple workloads share a single processing  
      environment, the Contractor ID will reflect the contractor ID of the       
primary workload. 
 
Data Element:  Record Type 
Definition:    Code indicating type of record  
Validation:    N/A 
Remarks:    2 = claim record  
Requirement:    Required 
 
Data Element:  Record Version Code 
Definition:   The code indicating the record version of the Claim Universe file.  
Validation:   Claim Universe files prior to 7/1/2007 did not contain this field. 
     Codes: 
     B = Record Format as of 7/1/2007 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Contractor Type  
Definition:   Type of Medicare Contractor.  
     
Validation:   Must be B or D 
Remarks:   B = A/B MAC (B) 
     D = DME MAC 
Requirement:   Required 
 
Data Element:  Claim Control Number 
Definition:   Number assigned by the shared system to uniquely identify the claim.  
Validation:   N/A 
Remarks:  Reflects the Claim Control Number selected from the Claim Universe    file  in 
the sampling process. 
Requirement:   Required 
 
Data Element:  Beneficiary HICN 
Definition:   Beneficiarys Health Insurance Claim Number  
Validation:   N/A 
Remarks:   Reflects the Beneficiary HICN on the claim record selected from the  
  Claim Universe file in the sampling process 
Requirement:   Required 
 
Claims Transaction File 
Claims Transaction Trailer Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  3 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Number of Claims  9(9)  9  17  Zeroes 
 
DATA ELEMENT DETAIL 
 
Data Element:  Contractor ID 
Definition:        Contractors CMS assigned number  
Validation:        Must be a valid CMS contractor ID  
Remarks:    N/A 
Requirement:    Required 
NOTE:     For A/B MAC (B): when multiple workloads share a single processing  
      environment, the Contractor ID will reflect the contractor ID of the       
primary workload. 
 
Data Element:  Record Type 
Definition:    Code indicating type of record.  
Validation:    N/A 
Remarks:    3 = Trailer Record  
Requirement:    Required 
 
Data Element:  Record Version Code 
Definition:   The code indicating the record version of the Claim Universe file.  
Validation:   Claim Universe files prior to 7/1/2007 did not contain this field. 
     Codes: 
     
     B = Record Format as of 7/1/2007 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Contractor Type  
Definition:   Type of Medicare Contractor.  
Validation:   Must be B or D 
Remarks:   B = A/B MAC (B) 
     D = DME MAC 
Requirement:   Required 
 
Data Element:  Number of Claims 
Definition:   Number of claim records on this file. 
Validation:   Must be equal to the number of claim records on the file.  
Remarks:   Do not count header or trailer records. 
Requirement:   Required 
 
Claims Resolution File 
Claims Resolution Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  1 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Resolution Date  X(8)  9  16  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element:  Contractor ID 
Definition:         Contractors CMS assigned number.  
Validation:        Must be a valid CMS contractor ID.  
Remarks:    N/A 
Requirement:    Required 
NOTE:     For A/B MAC (B): when multiple workloads share a single processing  
      environment, the Contractor ID will reflect the contractor ID of the       
primary workload. 
 
Data Element:  Record Type 
Definition:   Code indicating type of record.  
Validation:   N/A 
Remarks:   1 = Header record  
Requirement:   Required 
 
Data Element:  Record Version Code 
Definition:   The code indicating the record version of the Claim Resolution file.  
Validation:   Claim Resolution files prior to 7/1/2007 did not contain this field. 
     Codes: 
     B = Record Format as of 7/1/2007  
     C = Record Format as of 1/1/2010 
     
     D = Record Format as of 7/1/2016  
     E = Record Format as of 10/1/2017 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Contractor Type  
Definition:   Type of Medicare Contractor  
Validation:   Must be B or D 
Remarks:   B = A/B MAC (B) 
     D = DME MAC 
Requirement:   Required 
 
Data Element:  Resolution Date 
Definition:   Date the Resolution Record was created. 
Validation:   Must be a valid date not equal to a Resolution date sent on any previous      
claims Resolution file. 
Remarks:   Format is CCYYMMDD. May use shared system batch processing date. 
Requirement:   Required 
 
Sampled Claims Resolution File 
Sampled Claims Resolution Detail Record (one record per claim) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  2 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Assignment Indicator  X(1)  9  9  Spaces 
Mode of Entry Indicator  X(1)  10  10  Spaces 
Original Claim Control Number  X(15)  11  25  Spaces 
Claim Control Number  X(15)  26  40  Spaces 
Beneficiary HICN  X(12)  41  52  Spaces 
Beneficiary Last Name  X(60)  53  112  Spaces 
Beneficiary First Name  X(35)  113  147  Spaces 
Beneficiary Middle Initial  X(1)  148  148  Spaces 
Beneficiary Date Of Birth  X(8)  149  156  Spaces 
Billing Provider Number  X(15)  157  171  Spaces 
Referring/Ordering UPIN  X(6)  172  177  Spaces 
Claim Allowed Amount  S9(7)v99  178  186  Zeroes 
Claim ANSI Reason Code 1  X(8)  187  194  Spaces 
Claim ANSI Reason Code 2  X(8)  195  202  Spaces 
Claim ANSI Reason Code 3  X(8)  203  210  Spaces 
Claim Entry Date  X(8)  211  218  Spaces 
Claim Adjudicated Date  X(8)  219  226  Spaces 
Beneficiary Gender  X(1)  227  227  Spaces 
Billing Provider NPI  X(10)  228  237  Spaces 
Referring/Ordering Provider NPI  X(10)  238  247  Spaces 
Claim Paid Amount  S9(7)v99  248  256  Zeroes 
Beneficiary Paid Amount  S9(7)v99  257  265  Zeroes 
Claim Diagnosis Code 1  X(7)  266  272  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
Claim Diagnosis Code 1Version  X(1)  273  273  Spaces 
Indicator Code 
Claim Diagnosis Code 2  X(7)  274  280  Spaces 
Claim Diagnosis Code 2Version  X(1)  281  281  Spaces 
Indicator Code 
Claim Diagnosis Code 3  X(7)  282  288  Spaces 
Claim Diagnosis Code 3Version  X(1)  289  289  Spaces 
Indicator Code 
Claim Diagnosis Code 4  X(7)  290  296  Spaces 
Claim Diagnosis Code 4Version  X(1)  297  297  Spaces 
Indicator Code 
Claim Diagnosis Code 5  X(7)  298  304  Spaces 
Claim Diagnosis Code 5Version  X(1)  305  305  Spaces 
Indicator Code 
Claim Diagnosis Code 6  X(7)  306  312  Spaces 
Claim Diagnosis Code 6Version  X(1)  313  313  Spaces 
Indicator Code 
Claim Diagnosis Code 7  X(7)  314  320  Spaces 
Claim Diagnosis Code 7Version  X(1)  321  321  Spaces 
Indicator Code 
Claim Diagnosis Code 8  X(7)  322  328  Spaces 
Claim Diagnosis Code 8Version  X(1)  329  329  Spaces 
Indicator Code 
Claim Diagnosis Code 9  X(7)  330  336  Spaces 
Claim Diagnosis Code 9Version  X(1)  337  337  Spaces 
Indicator Code 
Claim Diagnosis Code 10  X(7)  338  344  Spaces 
Claim Diagnosis Code 10Version  X(1)  345  345  Spaces 
Indicator Code 
Claim Diagnosis Code 11  X(7)  346  352  Spaces 
Claim Diagnosis Code 11Version  X(1)  353  353  Spaces 
Indicator Code 
Claim Diagnosis Code 12  X(7)  354  360  Spaces 
Claim Diagnosis Code 12Version  X(1)  361  361  Spaces 
Indicator Code 
Claim Zip Code  X(9)  362  370  Spaces 
Claim Pricing State  X(2)  371  372  Spaces 
Beneficiary Zip Code  X(9)  373  381  Spaces 
Beneficiary State  X(2)  382  383  Spaces 
Claim Demonstration Number  X(2)  384  385  Spaces 
RAC Adjustment Indicator  X(1)  386  386  Spaces 
Split/Adjustment Indicator  X(2)  387  388  Spaces 
Facility NPI  X(10)  389  398  Spaces 
Claim PWK  X(60)  399  458  Spaces 
Claim Demonstration Identification  X(2)  459  460  Spaces 
Number2 
Claim Demonstration Identification  X(2)  461  462  Spaces 
Number3 
Claim Demonstration Identification  X(2)  463  464  Spaces 
Number4 
     
Field Name  Picture  From  Thru  Initialization 
Beneficiary MBI  X(11)  465  475  Spaces 
HICN/MBI indicator  X(1)  476  476  Spaces 
Line Item Count  9(2)  477  478  Zeroes 
Filler  X(32)  479  510  Spaces 
 
Sampled Claims Resolution File 
Sampled Claims Resolution Line Item Detail Group 
*The following group of fields occurs from 1 to 13 times   (Depending on Line Item Count). 
st 
*From and Thru values relate to the 1 line item 
 
Field Name  Picture  From  Thru  Initialization 
Performing Provider Number  X(15)  511  525  Spaces 
Performing Provider Specialty  X(2)  526  527  Spaces 
HCPCS Procedure Code  X(5)  528  532  Spaces 
HCPCS Modifier 1  X(2)  533  534  Spaces 
HCPCS Modifier 2  X(2)  535  536  Spaces 
HCPCS Modifier 3  X(2)  537  538  Spaces 
HCPCS Modifier 4  X(2)  539  540  Spaces 
Number of Services  S9(7)v999  541  550  Zeroes 
Service From Date  X(8)  551  558  Spaces 
Service To Date  X(8)  559  566  Spaces 
Place of Service  X(2)  567  568  Spaces 
Type of Service  X(1)  569  569  Spaces 
Diagnosis Code  X(7)  570  576  Spaces 
Line Diagnosis Code Version  X(1)  577  577  Spaces 
Indicator Code 
CMN Control Number  X(15)  578  592  Spaces 
Line Submitted Charge  S9(7)v99  593  601  Zeroes 
Line Medicare Initial Allowed  S9(7)v99  602  610  Zeroes 
ANSI R eason Code 1  X(8)  611  618  Spaces 
ANSI Reason Code 2  X(8)  619  626  Spaces 
ANSI Reason Code 3  X(8)  627  634  Spaces 
ANSI Reason Code 4  X(8)  635  642  Spaces 
ANSI Reason Code 5  X(8)  643  650  Spaces 
ANSI Reason Code 6  X(8)  651  658  Spaces 
ANSI Reason Code 7  X(8)  659  666  Spaces 
Manual Medical Review Indicator  X(1)  667  667  Space 
Resolution Code  X(5)  668  672  Spaces 
Line Final Allowed Charge  S9(7)v99  673  681  Zeroes 
Performing Provider NPI  X(10)  682  691  Spaces 
Performing Provider UPIN  X(6)  692  697  Spaces 
Miles/Time/Units/Services Indicator X(1)  698  698  Spaces 
Code 
Line Deductible Applied  S9(7)v99  699  707  Zeroes 
Line Co-Insurance  S9(7)V99  708  716  Zeroes 
Line Paid Amount  S9(7)v99  717  725  Zeroes 
Line MSP Code  X(1)  726  726  Spaces 
Line MSP Paid Amount  S9(7)v99  727  735  Zeroes 
Line Pricing Locality  X(2)  736  737  Spaces 
     
Field Name  Picture  From  Thru  Initialization 
Line Zip Code  X(9)  738  746  Spaces 
Line Pricing State Code  X(2)  747  748  Spaces 
Ambulance Point of Pick up Zip  X(9)  749  757  Spaces 
Ambu lance Point of Drop Off Zip  X(9)  758  766  Spaces 
Code 
Line PWK  X(60)  767  826  Spaces 
Prior Authorization Program  X(4)  827  830  Spaces 
Unique T racking Number (UTN)  X(14)  831  844  Spaces 
Prior Authorization Affirmed  X(1)  845  845  Spaces 
Indicator 
Filler  X(6)  846  851  Spaces 
 
DATA ELEMENT DETAIL 
 
Claim (Header) Fields 
 
Data Element:  Contractor ID 
Definition:        Contractors CMS assigned number  
Validation:        Must be a valid CMS contractor ID  
Remarks:    N/A 
Requirement:    Required 
NOTE:     For A/B MAC (B): when multiple workloads share a single processing  
      environment, the Contractor ID will reflect the contractor ID of the       
primary workload. 
 
Data Element:  Record Type 
Definition:   Code indicating type of record  
Validation:   N/A 
Remarks:   2 = Claim record  
Requirement:   Required 
 
Data Element:  Record Version Code 
Definition:   The code indicating the record version of the Claim Resolution file.  
Validation:   Claim Resolution files prior to 7/1/2007 did not contain this field. 
     Codes: 
     B = Record Format as of 7/1/2007  
     C = Record Format as of 1/1/2010  
     D = Record Format as of 7/1/2016  
     E = Record Format as of 10/1/2017 
Remarks:   N/A 
Requirement:   Required 
 
Data Element:  Contractor Type  
Definition:   Type of Medicare Contractor.  
Validation:   Must be B or D 
Remarks:   B = A/B MAC (B) 
     D = DME MAC 
Requirement:   Required 
 
     
Data Element:  Assignment Indicator 
Definition:   Code indicating whether claim is assigned or non-assigned.  
Validation:   Must be A or N 
Remarks:   A = Assigned 
      N = Non-assigned  
Requirement:   Required 
 
Data Element:  Mode of Entry Indicator 
Definition:   Code that indicates if the claim is paper or EMC.  
Validation:   Must be E or P 
Remarks:   E = EMC P = Paper 
     Use the same criteria to determine EMC or paper as that used for    
  workload reporting. 
Requirement:   Required 
 
Data Element:  Original Claim Control Number 
Definition:   The Claim Control Number the shared system assigned to the claim in  
 the Universe file.  This number should be the same as the claim control    
number for the claim in the Sample Claims Transactions file, and the   claim control 
number for the claim on the Universe file.  If the shared    system had to use a 
crosswalk to pull the claim because the MAC or   shared system changed the claim 
control number during processing, 
enter the number the shared system used to look up the number needed 
to pull  all records associated with the sample claim. 
Validation:   Must match the Claim Control Number identified in the Sampled  
Claims Transaction File. 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Claim Control Number 
Definition:   Number assigned by the shared system to uniquely identify the claim.  
Validation:   N/A 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Beneficiary HICN 
Definition:   Beneficiarys Health Insurance Claim Number.  
Validation:   N/A 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Beneficiary Last Name 
Definition:   Last Name (Surname) of the beneficiary.  
Validation:   N/A 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Beneficiary First Name 
Definition:   First (Given) Name of the beneficiary.  
     
Validation:   N/A 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Beneficiary Middle Initial 
Definition:   First letter from Beneficiary Middle Name. 
Validation:   N/A 
Remarks:   N/A 
Requirement:   Required when available 
 
Data Element:  Beneficiary Date of Birth  
Definition:   Date on which beneficiary was born.  
Validation:   Must be a valid date 
Remarks:   MMDDCCYY on which the beneficiary was born.  
Requirement:   Required 
 
Data Element:  Billing Provider Number 
Definition:    Number assigned by the National Supplier Clearinghouse (NSC) or MAC  
    to identify the billing/pricing provider or supplier. 
Validation:    Must be present. Use the same requirements as for Item 33 in HCFA       
1500. 
  Enter the PIN, for the performing provider of service/supplier  
who is not a member of a group practice. 
  Enter the group PIN, for the performing provider of   
service/supplier who is a member of a group practice. 
  Suppliers billing the DME MAC will use the National Supplier  
  Clearinghouse (NSC) number in this item. 
  If the same billing/pricing provider number does not apply to all  
  lines on the claim, enter the Billing provider number that applies  
  to the performing provider on the first line of the claim. 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  Referring/Ordering UPIN 
Definition:  UPIN assigned to identify the referring/ordering provider.  
Validation:  N/A 
Remarks:  Enter zeros if there is no referring/ordering provider. 
  Referring physician - is a physician who requests an item or  
  service for the beneficiary for which payment may be made 
 under  the Medicare program. 
  Ordering physician - is a physician or, when appropriate, a non- 
  physician practitioner who orders non-physician services for the     patient. 
Requirement:  Required when available on the claim record. 
 
Data Element:  Claim Allowed Amount 
Definition:  Final Allowed Amount for this claim.  
Validation:  N/A 
Remarks:  The total allowed charges on the claim (the sum of line item allowed  
  charges)  
     
Requirement:  Required 
 
Data Element:  Claim ANSI Reason Code 1-3 
Definition:  Codes showing the reason for any adjustments to this claim, such as  
  denials or reductions of payment from the amount billed. 
Validation:  Must be valid ANSI ASC claim adjustment codes and applicable group  
  codes.  
Remarks:  Format is GGRRRRRR where:  GG is the group code and RRRRRR is 
the adjustment reason code. 
Requirement:  ANSI Reason Code 1 must be present on all claims.  Codes 2 and 3 should 
  be sent, if available. 
 
Data Element:  Claim Entry Date 
Definition:  Date claim entered the shared claim processing system  
Validation:  Must be a valid date 
Remarks:  Format must be CCYYMMDD  
Requirement:  Required 
 
Data Element:  Claim Adjudicated Date 
Definition:   Date claim completed adjudication. 
Validation:   Must be a valid date.  Format must be CCYYMMDD. 
Remarks:  This must represent the processed date that may be prior to the pay date if the 
claim is held on the payment floor after a payment decision has been  made. 
Requirement:   Required 
 
Data Element:  Beneficiary Gender  
Definition:  Gender of the Beneficiary. 
Validation:  M=Male 
    F=Female  
    U=Unknown 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  Billing Provider NPI 
Definition:  NPI assigned to the Billing Provider.  
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required 
 
Data Element:  Referring/Ordering Provider NPI 
Definition:  NPI assigned to the Referring/Ordering Provider. 
Validation:  N/A 
Remarks:  Enter zeros if there is no referring/ordering provider. 
  Referring physician - is a physician who requests an item or   service 
for the beneficiary for which payment may be made  
  under  the Medicare program. 
  Ordering physician - is a physician or, when appropriate, a non-
  physician practitioner who orders non-physician services for the   patient. 
Requirement:  Required when available on the claim record. 
     
 
Data Element:  Claim Paid Amount 
Definition:  Net amount paid after co-insurance and deductible.  Do not include  
  interest you paid in the amount reported. 
Validation:  N/A 
Remarks:  Amount of payment made from the Medicare trust fund for the services  
  covered by the claim record. 
Requirement:  Required 
 
Data Element:  Beneficiary Paid Amount 
Definition:  Amount paid by Beneficiary to the provider. 
Validation:  N/A 
Remarks:  N/A 
Requirement:  Required if available. 
 
Data Element:  Claim Diagnosis Code 1-12 
Definition:  The ICD-CM diagnosis code identifying the diagnosis, condition, 
problem or other reason for the admission/encounter/visit shown in the medical 
record to be chiefly responsible for the services provided. 
Validation:  Must be a valid ICD-CM diagnosis code. 
  CMS accepts only CMS approved ICD-CM diagnostic and procedural 
codes. The CMS approves only changes issued by the Federal ICD-CM 
Coordination and Maintenance Committee. 
  Diagnosis codes must be full ICD-CM diagnoses codes, including the full 
number of digits (five for ICD-9-CM, seven for ICD-10-CM) where 
applicable. 
Remarks: 
  These fields should be left justified and space filled.  For instance if the 
primary diagnosis on the claim is five positions long, this field should contain 
the diagnosis with 2 spaces at the end. 
  With the exception of claims submitted by ambulance suppliers (specialty 
type 59), all claims submitted on HCFA 1500 by physician and non-physician 
specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code 
to the highest level of specificity for the date of service. Independent 
laboratories enter a diagnosis only for limited coverage procedures.  Since this 
is a required field, resolution records for claims billed by Ambulance suppliers 
and independent clinical laboratories must include the following filler 
information when the diagnosis is not otherwise available: 
  Ambulance supplier (specialty 59)amb 
  Independent Clinical Lab (specialty 69)--lab 
Requirement:   Claim Diagnosis 1 is required for ALL claims. 
     Claim diagnosis codes 2-12 should be submitted if contained on the 
 claim record. Enter spaces for the diagnosis code fields that are not  
 populated on the claim record in the Shared Processing System. 
 
Data Element:  Claim Diagnosis Version Indicator Code 1-12 
Definition:   The ICD--CM diagnosis version code identifying the version of  
    diagnosis  code submitted. 
Validation:        Version ICD9 use Version Code 9 
     
  Version ICD10 use Version Code 0 
  May be blank for claims billed by ambulance and independent 
laboratory suppliers. 
Remarks:  With the exception of claims submitted by ambulance suppliers (specialty type 
59), all claims submitted on HCFA 1500 by physician and non-physician 
specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code to 
the highest level of specificity for the date of service. Independent laboratories 
enter a diagnosis only for limited coverage  procedures. 
Requirement:   Claim Diagnosis Version Code 1 is required for ALL claims, except 
 those billed by ambulance and independent laboratories.  Claim 
diagnosis version codes 2-12 should be submitted to correspond to claim 
 level diagnosis codes 2-12. 
 
Data Element:  Claim Zip Code 
Definition:   Zip Code used to identify were the service was furnished.  
Validation:   Must be a valid Zip Code 
  This field should be left justified and zero filled.  When only a 
five digit zip code is carried in the Shared Processing System, this field 
will contain the five digit zip code followed by 4 zeros. 
Remarks:   For DME MAC Claims use the zip code for beneficiary residence. 
     For Part B Claims, use the zip code identified in item 32 of the HCFA  
  1500, except in the listed situations. 
  For ambulance services, identify the zip code where the patient was 
picked up. 
  If the service was furnished in the patients home, use the zip code from 
the patients home address. 
  For electronic claims, if multiple zip codes are identified enter the zip 
code for the line with the highest allowed amount. (If this logic is too 
cumbersome to implement, we can live with enter the zip code from the 
first line). 
Requirement:   Required 
 
Data Element:  Claim Pricing State 
Definition:   State where services were furnished. 
Validation:   Must be a valid 2 digit state abbreviation as defined by the United States  
  Postal Service (USPS). 
Remarks:   Furnish the state associated with the Claim Zip Code. 
Requirement:   Required 
 
Data Element:  Beneficiary Zip Code 
Definition:   Zip Code associated with the beneficiary residence.  
Validation:   Must be a valid Zip Code 
  This field should be left justified and zero filled.  When only a  
five digit zip code is carried in the Shared Processing System, 
this field will contain the five digit zip code followed by 4 zeros. 
Remarks:   Use the zip code for beneficiary residence. 
Requirement:   Required 
 
Data Element:  Beneficiary State 
     
Definition:   State abbreviation identifying the state in which the beneficiary resides.  
Validation:   Must be a valid 2 digit state abbreviation as defined by the United States  Postal 
Service (USPS). 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Claim Demonstration Number 
Definition:       This element is also known as the Claim Demonstration Identification  
  Number. It is the number assigned to identify a demonstration Project.     This 
field is also used to denote special processing (a.k.a. Special       Processing 
Number, SPN). 
Validation:   Must be a Valid Demo ID. 
Remarks:   Must be populated with the value from the first populated demonstration      
number on the claim. 
Requirement:   Required on every claim processed under a CMS demonstration project. 
 
Data Element:  RAC Adjustment Indicator 
Definition:   Indicator used to identify RAC requested adjustments, which occur as a  
  result of post-payment review activities done by the Recovery Audit  
  Contractors (RAC). 
Validation:   R identifies a RAC-requested adjustment  
Remarks:   N/A 
Requirement:   Required when RAC adjustment indicator was furnished to CWF 
 
Data Element:  Split/Adjustment Indicator 
Definition:   Count of number of splits/replicates/adjustments (with different claim  
  control numbers (ICN/CCN)) of the sampled claim that are included in     the 
resolution file. 
Validation:   00 is used when only one claim control number (ICN/CCN) associated      
with the sampled claim is included in the resolution file. 
     When the resolution file contains multiple adjustments/splits/replicates  
     associated with a single claim, this field will provide a count of records. 
  For example, if the file contains the original, replicate and  
 adjustment claims, one record would have an indicator of 01, 
   one record would have an indicator of 02, and the third record  
   would have an indicator of 03. 
Remarks:   This indicator does not apply when multiple records are submitted for a      
single claim record because of size restrictions. 
     This field is right justified and zero filled. 
Requirement:   Required when the resolution file contains multiple versions of a single claim. 
 
Data Element:  Facility NPI 
Definition:    The NPI of the facility at which the service was performed. 
Validation:    N/A 
Remarks:    N/A 
Requirement:    Required when available on the claim record. 
 
Data Element:  PWK 
Definition:    Space reserved for future use. 
     
Validation:    N/A 
Remarks:    N/A 
Requirement:    Required when available on the claim record. 
 
Data Element:  Claim Demonstration Number 2 
Definition:        This element is also known as the Claim Demonstration Identification      
Number. It is the number assigned to identify a demonstration Project.     This field is 
also used to denote special processing (a.k.a. Special       Processing Number, 
SPN). 
Validation:    Must be a Valid Demo ID. 
Remarks:    Must be populated with the value from the second populated        
demonstration number on the claim. 
Requirement:    Required when present on claim. 
 
Data Element:  Claim Demonstration Number 3 
Definition:        This element is also known as the Claim Demonstration Identification      
Number. It is the number assigned to identify a demonstration Project.      This field is 
also used to denote special processing (a.k.a. Special        Processing Number, 
SPN). 
Validation:    Must be a Valid Demo ID. 
Remarks:   Must be populated with the value from the third populated   demonstration 
number on the claim. 
Requirement:    Required when present on claim 
 
Data Element:  Claim Demonstration Number 4 
Definition:        This element is also known as the Claim Demonstration Identification       
Number. It is the number assigned to identify a demonstration Project.       This field is 
also used to denote special processing (a.k.a. Special        Processing Number, 
SPN). 
Validation:    Must be a Valid Demo ID 
Remarks:    Must be populated with the value from the fourth populated        
demonstration number on the claim. 
Requirement:    Required when present on claim 
 
Data Element:   Beneficiary MBI 
Definition:    Beneficiarys Medicare Beneficiary Identifier  
Validation:    Comply with CMS Standards 
  11-character, fixed length alpha-numeric string. 
  Different, visibly distinguishable from 
HICN/RRB  
         numbers. 
  Contain no more than 2 consecutive numbers. 
  Contain no more than 2 consecutive alphabetic characters 
  Must limit the possibility of letters being 
interpreted as 
          numbers (i.e., alphabetic characters [A...Z]; excluding S, 
  L, O, I, B, Z). 
  Must not contain lowercase letters. 
  Must not contain any special characters.  
     
Remarks:    Do not include hyphens or spaces.  
Requirement:   Required 
Data Element:  HICN/MBI Indicator 
Definition:   Indicator that identifies if the provider submitted the claim with a HICN  
  or MBI.  
Validation: 
     M = MBI submitted on the claim  
     H = HICN submitted on the claim 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Line Item Count 
Definition:  Number indicating number of service lines on the claim  
Validation:  Must be a number 01  52 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  Filler 
Definition:  Additional space -- use to be determined  
Validation:  N/A 
Remarks:  N/A  
Requirement:  Required 
 
Claim Line Item Fields 
 
Data Element:  Performing Provider Number 
Definition:  Number assigned by the shared system to identify the provider who performed the 
service or the supplier who supplied the medical equipment. 
Validation:   N/A 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Performing Provider Specialty 
Definition:   Code indicating the primary specialty of the performing provider or  
  supplier.  
Validation:   Must be a valid Provider Specialty per IOM 10.4 ch26 10.8. 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  HCPCS Procedure Code 
Definition:   The HCPCS/CPT-4 code that describes the service.  
Validation:   N/A 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  HCPCS Modifier 1-4 
Definition:   Codes identifying special circumstances related to the service.  
Validation:   N/A 
Remarks:   N/A 
     
Requirement:   Required if available 
 
Data Element:  Number of Services 
Definition:   The number of service rendered in days or units.  
Validation:   N/A 
Remarks:   Zero filled to maintain the relative position of the decimal point. 
     The last three positions should contain the value to the right of the  
  decimal in the number of services.  Put a zero in the last three positions     for 
whole numbers.  For example if the number of units is 10, this field     would be 
filled as 0000010000. 
Requirement:   Required 
 
Data Element:  Service from Date 
Definition:   The date the service was initiated. 
Validation:   Must be a valid date less than or equal to Service to Date.  
Remarks:   Format is CCYYMMDD 
Requirement:   Required 
 
Data Element:  Service to Date 
Definition:   The date the service ended. 
Validation:   Must be a valid date greater than or equal to Service from Date.  
Remarks:   Format is CCYYMMDD. 
Requirement:   Required 
 
Data Element:  Place of Service 
Definition:   Code that identifies where the service was performed. 
Validation:   N/A 
Remarks:   Must be a value in the range of 00-99.  
Requirement:   Required 
 
Data Element:  Type of Service 
Definition:   Code that classifies the service. 
Validation:   The code must match a valid CWF type of service code.  
Remarks:   N/A 
Requirement:   Required 
 
Data Element:  Diagnosis Code 
Definition:   Code identifying a diagnosed medical condition resulting in the line item service.  
Validation:   Must be a valid ICD-CM diagnosis code. 
  CMS accepts only CMS approved ICD-CM diagnostic and procedural 
codes.  The CMS approves only changes issued by the Federal ICD-CM 
Coordination and Maintenance Committee. 
  Diagnosis codes must be full ICD-CM diagnoses codes, including the full 
number of digits (five for ICD-9-CM, seven for ICD-10-CM) where 
applicable. 
Remarks:   With the exception of claims submitted by ambulance suppliers (specialty  type 
59), all claims submitted on HCFA 1500 by physician and non-physician 
specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code to 
the highest level of specificity for the date of service. Independent laboratories 
     
enter a diagnosis only for limited coverage procedures.  Since this is a required 
field, resolution records for claims billed by Ambulance suppliers and 
independent clinical laboratories must include the following filler information 
when the diagnosis is not otherwise available: 
  Ambulance supplier (specialty 59)amb 
  Independent Clinical Lab (specialty 69)--lab  
Requirement:   Required 
 
Data Element:  Line Diagnosis Code Version Indicator Code 
Definition:  The ICD--CM diagnosis version code identifying the version of diagnosis code 
submitted. 
Validation:    Version ICD9 use Version Code 9 
  Version ICD10 use Version Code 0 
  May be blank for claims billed by ambulance and independent 
laboratory suppliers. 
Remarks:   With the exception of claims submitted by ambulance suppliers (specialty type 
59), all claims submitted on HCFA 1500 by physician and non-physician 
specialties (i.e., PA, NP, CNS, CRNA) use an ICD-CM code number and code to 
the highest level of specificity for the date of service. Independent laboratories 
enter a diagnosis only for limited coverage procedures. 
Requirement:  Diagnosis Version Code is required for ALL lines, except those billed by 
ambulance and independent clinical laboratory suppliers. 
 
Data Element:  CMN Control Number 
Definition:   Number assigned by the shared system to uniquely identify a Certificate  
  of Medical Necessity. 
Validation:   N/A 
Remarks:   Enter a zero if no number is assigned.  
Requirement:   Required on DME claims 
 
Data Element:  Line Submitted Charge 
Definition:   Actual charge submitted by the provider or supplier for the service or      
equipment.  
Validation:   N/A 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Line Medicare Initial Allowed Charge 
Definition:  Amount Medicare allowed for the service or equipment before any       
reduction or denial. 
Validation:  N/A 
Remarks:  This charge is the lower of the fee schedule or billed amount (i.e., Submitted 
Charge), except for those services (e.g., ASC) that are always paid at the fee 
schedule amount even if it is higher than the Submitted Charge.  If there is no fee 
schedule amount, then insert the Submitted Charge. 
  Use MPFDB, Clinical Lab FS, Ambulance FS, ASC FS, drug and  
injectable FS, or DME fee schedule as appropriate. 
Requirement:   Required 
 
     
Data Element:  ANSI Reason Code 1-7 
Definition:   Codes showing the reason for any adjustments to this line, such as denials or 
reductions of payment from the amount billed. 
Validation:   Must be valid ANSI ASC claim adjustment codes and applicable group  
  codes.  
Remarks:    Format is GGRRRRRR where:  GG is the group code and RRRRRR is      
the adjustment reason code. 
Requirement:   ANSI Reason Code 1 must be present on all claims with resolutions of  
     'DENMR, 'DENMC' ,'DEO, 'RTP, 'REDMR, 'REDMC', or    
  'REO,APPAM,DENAM,REDAM. 
 
Data Element:  Manual Medical Review Indicator 
Definition:   Code indicating whether or not the service received complex manual medical 
review.  Complex review goes beyond routine review. It includes the request for, 
collection of, and evaluation of medical records or any other documentation in 
addition to the documentation on the claim, attached to the claim, or contained in 
the MACs history file.  The review   must require professional medical expertise 
and must be for the purpose of preventing payments of non-covered or incorrectly 
coded services. That includes reviews for the purpose of determining if services 
were medically necessary.  Professionals must perform the review, i.e., at a 
minimum, a Licensed Practical Nurse must perform the review. Review requiring 
use of the MAC's history file does not make the review a complex review.  A 
review is not considered complex if a medical record is requested from a provider 
and not received.  If sufficient documentation  accompanies a claim to allow 
complex review to be done without requesting additional documentation, count 
the review as complex. 
Validation:   Must be 'Y or N. 
Remarks:   Set to 'Y if service was subjected to complex manual medical review,      
else N.  
Requirement:   Required 
 
Data Element:  Resolution Code 
Definition:  Code indicating how the MAC resolved the line. 
 
Automated Review (AM): An automated review occurs when a claim/line item 
passes through the MAC's claims processing system or any adjunct system 
containing medical review edits. 
 
Routine Manual Review (MR):  Routine review uses human intervention, but only 
to the extent that the claim reviewer reviews a claim or any attachment submitted 
by the provider.  It includes review that involves review of any of the MAC's 
internal documentation, such as claims history file or policy documentation. It 
does not include review that involves review of medical records or other 
documentation requested from a provider.  A review is considered routine if a 
medical record is requested from a provider and not received.  Include prior 
authorization reviews in this category. 
 
Complex Manual Review (MC):  Complex review goes beyond routine review.  It 
includes the request for, collection of, and evaluation of medical records or any 
     
other documentation in addition to the documentation on the claim, attached to 
the claim, or contained in the MACs history file.  The review must require 
professional medical expertise and must be for the purpose of preventing 
payments of non-covered or incorrectly coded services.  Professionals must 
perform the review, i.e., at a minimum; a Licensed Practical Nurse must perform 
the review. Review requiring use of the MAC's history file does not make the 
review a complex review. A review is not considered complex if a medical record 
is requested from a provider and not received.  If sufficient documentation 
accompanies a claim to allow complex review to be done without requesting 
additional documentation, the review is complex.  For instance if all relevant 
pages from the patient's medical record are submitted with the claim, complex 
MR could be conducted without requesting additional documentation. 
 
Validation:  Must be APP, APPMR, APPMC,  DENMR,  DENMC,  DEO,  
  RTP, REDMR, REDMC, 'REO, DENAM, REDAM, DELET,     or 
TRANS, 
Remarks: 
 
Resolutio Descriptio
n Code   
APP  Approved as a valid submission without manual 
medical review. 
APPA Approved after automated medical review 
M  Approved after manual medical review 
APPM routine 
Approved after manual medical review complex. If 
this code is selected, set the Manual Medial Review 
DENA
Indicator to 'Y. 
M 
Denied after automated medical review 
DENM
Denied  for  medical  review  reasons  or  for 
R 
insufficient documentation of medical necessity, 
 
manual medical review routine 
Denied for medical review reasons or for insufficient   
           
     
Resolutio Descriptio
 
n Code 
Review Indicator to 'Y.' 
DEO  Denied for non-medical reasons, other than 
  denied as unprocessable. 
RTP  Denied as unprocessable 
REDA (return/reject) Reduced after 
M  medical review 
REDM Reduced for medical review reasons or for 
R  insufficient documentation of medical necessity, 
  manual medical review routine 
  Reduced for medical review reasons or for insufficient 
REDM
documentation of medical necessity, manual medical 
C 
review complex. If this code is selected, set the 
 
Manual Medial Review Indicator to 'Y.' 
 
Reduced for non-medical review reasons. 
 
Claim deleted from processing systemAC 
REO 
maintains record of claim on system   
 
Requirement:   Required 
 
Data Element:  Line Final Allowed Charge 
Definition:  Final Amount allowed for this service or equipment after any reduction or denial.  
Validation:   N/A 
Remarks:  This represents the MACs value of the service/item gross of co-pays and 
deductibles. 
Requirement:   Required 
 
Data Element:  Performing Provider NPI 
Definition:   NPI assigned to the Performing Provider.  
Validation:   N/A 
Remarks:   N/A. 
Requirement:   Required for providers that use HIPPA standard transactions. 
 
Data Element:  Performing Provider UPIN 
Definition:  Unique Physician Identifier Number (UPIN) that identifies the physician supplier 
actually performing/providing the service. 
Validation:   N/A 
Remarks:   N/A 
Requirement:   Required, when available 
 
Data Element:  Miles/Time/Units/Services Indicator 
Definition:   Code indicating the units associated with services needing unit reporting  on the 
line item for the Part B claim. 
Validation:   Must be a valid Indicator as identified in IOM 10.4 ch26 10.10. 
0-  No allowed services 
1-  Ambulance transportation miles  
2-  Anesthesia Time Units 
3-  Services 
     
4-   Oxygen units  
5-   Units of Blood 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Line Deductible Applied 
Definition:  Amount of deductible applied for this service or equipment.  
Validation:  N/A 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  Line Co-Insurance Amount 
Definition:   Amount of co-insurance due for this service or equipment.  
Validation:   N/A 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Line Paid Amount 
Definition:   Amount of payment made from the trust funds (after deductible and  
  coinsurance amounts have been paid) for the line item service on the 
 non-institutional claim. 
Validation:   N/A 
Remarks:   This represents the MACs value of the claim after co-pays and    
  deductibles.  
Requirement:   Required 
 
Data Element:  Line MSP Code 
Definition:   Code indicating primary payor for services on this line item.  
Validation:   A-Working Aged 
     B-ESRD 
     D-No-Fault 
     E-Workers' Compensation  
     F-Federal (Public Health)  
     G-Disabled 
     H-Black Lung  
     I-Veterans 
     L-Liability 
Remarks:   N/A 
Requirement:   Required, when contained on the claim record. 
 
Data Element:  Line MSP Paid Amount 
Definition:   The amount paid by the primary payer when the payer is primary to  
  Medicare (Medicare is secondary or tertiary). 
Validation:   N/A 
Remarks:   Amount paid by Primary Payer 
Requirement:   Required, when contained on the claim record. 
 
Data Element:  Line Pricing Locality 
Definition:   Code denoting the MAC-specific locality used for pricing this claim.  
     
Validation:   Must be a valid pricing locality. 
  Enter 00 for claims priced at a statewide locality.  
Requirement:   Required 
 
Data Element:  Line Zip Code 
Definition:   Zip Code used to determine claim pricing locality.  
Validation:   Must be a valid Zip Code 
     This field should be left justified and zero filled.  When only a five digit  
  zip code is carried in the Shared Processing System, this field will 
contain the five digit zip code followed by 4 zeros. 
Remarks:   For DME Claims use the zip code for beneficiary residence. 
     For Part B Claims, use the zip code identified in item 32 of the HCFA  
  1500, unless the service was furnished in the patients home.  If the     service 
was furnished in the patients home, use the zip code from the     patients home 
address. 
Requirement:   Required 
 
Data Element:  Line Pricing State 
Definition:   State where services were furnished. 
Validation:   Must be a valid 2 digit state abbreviation as defined by the United States  
  Postal Service (USPS). 
Remarks:   Furnish the state associated with the Line Zip Code.  
Requirement:   Required 
 
Data Element:  Ambulance Point of Pick-up Zip Code 
Definition:   Zip Code identifying the ambulance point of pick up.  
Validation:   Must be a valid Zip Code. 
Remarks:   This field should be left justified and zero filled.  When only a five digit      
zip code is carried in the Shared Processing System, this field will  
    contain the five digit zip code followed by 4 zeros. 
Requirement:   Required for ambulance claims 
 
Data Element:  Ambulance Drop Off Zip Code 
Definition:   Zip Code identifying the ambulance drop off point.  
Validation:   Must be a valid Zip Code. 
Remarks:   This field should be left justified and zero filled.  When only a five digit  
  zip code is carried in the Shared Processing System, this field will  
    contain the five digit zip code followed by 4 zeros. 
Requirement:   Required for ambulance claims 
 
Data Element:  PWK 
Definition:   Space reserved for future use.  
Validation:   N/A 
Remarks:   N/A 
Requirement:   Required when available on the claim record 
 
Data Element:   Prior Authorization Program Indicator 
Definition:   Prior Authorization Program Indicator issued by CMS to identify to      
which PA program the service belongs 
     
Validation:   Four character alphanumeric 
  The first character identifies the line of business 
  A for Part A, 
  B for Part B, 
  D for DME, 
  H for Home Health and Hospice 
  Followed by a three digit number 
Remarks:   N/A 
Requirement:   Required for claims containing services subject to a prior authorization    
   program. 
 
Data Element:  Unique Tracking Number (UTN)  
Definition:   Unique Tracking Number (UTN) assigned to the prior authorization      
request for the service or item. 
Validation:   For Prior Authorization Claims/services the UTN shall be 14 characters    
   and use the following format: 
  First two characters = MAC identifier (e.g. RR for Railroad, 0F for 
Jurisdiction F, 05 for Jurisdiction 5, etc.). 
  Third character = line of business (e.g. A for Part A, B for Part B, D for 
DME, H for Home Health and Hospice). 
  Remaining numerical characters = a unique sequence number assigned by 
the Shared System. 
       For claims/services in the PMD Prior Authorization Project, the 
 UTN shall be 14 characters and use the following format: 
  First character = DME MAC identifier (e.g. A for Jurisdiction A, B for 
Jurisdiction B, etc.). 
  Second and third characters = 00 (zero and zero). 
  Remaining characters = a unique sequence number assigned by the Shared 
System. 
Remarks:   N/A 
Requirement:   Required for claims containing services covered by an affirmed prior  
  authorization. 
 
Data Element:  Prior Auth Affirmed 
Definition:   Code to identify if the prior authorization for the service(s) on this line      
was affirmed. 
Validation:        Y indicates the prior authorization was affirmed. 
      N indicates the prior authorization was not affirmed. 
      Default value is blank for services that are not part of prior    
  authorization demonstration. 
Remarks:   N/A 
Requirement:   Required for claims containing services subject to prior authorization in      
the state where the service was furnished. 
 
Data Element:  Filler 
Definition:   Additional space TBD.  
Validation:   N/A 
Remarks:   N/A  
Requirement:   None 
     
 
Claims Resolution File 
Claims Resolution Trailer Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  3 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Number of Claims  9(9)  9  1617  Zeroes 
 
DATA ELEMENT DETAIL 
 
Data Element: Contractor ID 
Definition:  Contractors CMS assigned number.  
Validation:  Must be a valid CMS contractor ID.  
Remarks:  N/A 
Requirement:  Required 
NOTE:   For A/B MAC (B): When multiple workloads share a single processing  
  environment, the Contractor ID will reflect the contractor ID of the  
  primary workload. 
 
Data Element:  Record Type 
Definition:   Code indicating type of record.  
Validation:   N/A 
Remarks:   3 = Trailer Record  
Requirement:   Required 
 
Data Element:  Record Version Code 
Definition:   The code indicating the record version of the Claim Resolution file.  
Validation:   Claim Resolution files prior to 7/1/2007 did not contain this field. 
     Codes: 
     B = Record Format as of 7/1/2007  
     C = Record Format as of 1/1/2010  
     D = Record Format as of 7/1/2016  
     E = Record Format as of 10/1/2017 
Remarks:   N/A  
Requirement:   Required 
 
Data Element:  Contractor Type  
Definition:   Type of Medicare Contractor.  
Validation:   Must be B or D 
Remarks:   B = A/B MAC (B) 
               D = DME MAC 
Requirement:   Required 
 
Data Element:  Number of Claims 
Definition:   Number of claim records on this file. 
Validation:   Must be equal to the number of claim records on the file.  
Remarks:   Do not count header or trailer records. 
     
Requirement:   Required 
 
Claims Provider Address File 
Claims Provider Address Header Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  1 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Provider Address Date  X(8)  9  16  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element:  Contractor ID 
Definition:        Contractors CMS assigned number.  
Validation:        Must be a valid CMS contractor ID.  
Remarks:    N/A 
Requirement:    Required 
NOTE:     For A/B MAC (B): when multiple workloads share a single processing  
      environment, the Contractor ID will reflect the contractor ID of the               
primary workload. 
 
Data Element:  Record Type 
Definition:  Code indicating type of record.  
Validation:  N/A 
Remarks:  1 = Header record  
Requirement:  Required 
 
Data Element:  Record Version Code 
Definition:  The code indicating the record version of the Claim Provider Address 
file.  
Validation:  Claim Provider Address files prior to 7/1/2007 did not contain this field. 
    Codes: 
    B = Record Format as of 7/1/2007  
    C = Record Format as of 1/1/2010 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  Contractor Type  
Definition:  Type of Medicare Contractor.  
Validation:  Must be B or D 
Remarks:  B = A/B MAC (B) 
    D = DME MAC 
Requirement:  Required 
 
Data Element:  Provider Address Date 
Definition:  Date the Provider Address File was created. 
Validation:  Must be a valid date not equal to a Provider Address date sent on any  
  previous claims Provider Address file. 
     
Remarks:  Format is CCYYMMDD. May use shared system batch processing date. 
Requirement:  Required 
 
Provider Address File 
Provider Address Detail Record 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  2 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Provider Number/NPI  X(15)  9  23  Spaces 
Provider Name  X(60)  24  83  Spaces 
Provider Address 1  X(25)  84  108  Spaces 
Provider Address 2  X(25)  109  133  Spaces 
Provider City  X(15)  134  148  Spaces 
Provider State Code  X(2)  149  150  Spaces 
Provider Zip Code  X(9)  151  159  Spaces 
Provider Phone Number  X(10)  160  169  Spaces 
Provider Phone Number Extension  X(10)  170  179  Spaces 
Provider Fax Number  X(10)  180  189  Spaces 
Provider Type  X(2)  190  191  Spaces 
Provider Address Order  X(2)  192  193  Spaces 
Provider Address Type  9(3)  194  196  Zero 
Provider E-mail Address  X(75)  197  271  Spaces 
Provider Federal Tax number or EIN  9(10)  272  281  Zeroes 
Provider Taxonomy Code  9(10)  282  291  Zeroes 
Provider License Number  X(16)  292  307  Spaces 
Provider License State  X(2)  308  309  Spaces 
Filler  X(25)  310  334  Spaces 
 
DATA ELEMENT DETAIL 
 
Data Element:  Contractor ID 
Definition:        Contractors CMS assigned number.  
Validation:        Must be a valid CMS contractor ID.  
Remarks:    N/A 
Requirement:    Required 
NOTE:     For A/B MAC (B): when multiple workloads share a single processing  
      environment, the Contractor ID will reflect the contractor ID of the       
primary workload. 
 
Data Element:  Record Type 
Definition:   Code indicating type of record.  
Validation:   N/A 
Remarks:   2 = claim record  
Requirement:   Required 
 
Data Element:  Record Version Code 
Definition:   The code indicating the record version of the Claim Universe file.  
     
Validation:   Claim Universe files prior to 7/1/2007 did not contain this field. 
     Codes: 
     B = Record Format as of 7/1/2007  
     C = Record Format as of 1/1/2010 
Remarks:   N/A  
Requirement:   Required 
Data Element:  Contractor Type  
Definition:  Type of Medicare Contractor.  
Validation:  Must be B or D 
Remarks:  B = A/B MAC (B) 
    D = DME MAC 
Requirement:  Required 
 
Data Element:  Provider Number/NPI 
Definition:  Number assigned by the MAC/NSC or NPI agency to identify the provider. 
Validation:  N/A 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  Provider Name  
Definition:       Providers name.  
Validation:      N/A 
Remarks:  This is the name of the provider. 
    The provider name must be formatted into a business name for mailing  
  (e.g. Roger A Smith M.D. or Medical Associates, Inc). 
    Where possible this should contain the Legal Business Name as carried 
in the Shared Processing System. 
Requirement:  Required 
 
Data Element:  Provider Address 1  
Definition:  1st line of providers address.  
Validation:  N/A 
Remarks:  This is the address1 of the provider.  
Requirement:  Required 
 
Data Element:  Provider Address 2  
Definition:  2nd line of providers address.  
Validation:  N/A 
Remarks:  This is the address2 of the provider.  
Requirement:  Required if available 
 
Data Element:  Provider City  
Definition:  Providers city name.  
Validation:  N/A 
Remarks:  This is the city of the providers address.  
Requirement:  Required 
 
Data Element:  Provider State Code  
Definition:  Providers state code.  
     
Validation:  Must be a valid state code. 
Remarks:  This is the state of the providers address. 
Requirement:  Required 
 
Data Element:  Provider Zip Code  
Definition:  Providers zip code.  
Validation:  Must be a valid postal zip code. 
Remarks:  This is the zip code of the providers address.  Provide 9-digit zip code if  
    available, otherwise provide 5-digit zip code. 
    This field should be left justified and zero filled.  When only a five digit  
  zip code is carried in the Shared Processing System, this field will  
    contain the five digit zip code followed by 4 zeros. 
Requirement:  Required 
 
Data Element:  Provider Phone Number  
Definition:  Providers telephone number..  
Validation:  Must be a valid telephone number.  
Remarks:  This is the phone number.  
Requirement:  None 
 
Data Element:  Provider Phone Number Extension  
Definition:  Providers telephone number Extension.  
Validation:  Must be a valid telephone number.  
Remarks:  This is the phone number.   
Requirement:  None 
 
Data Element:  Provider Fax Number  
Definition:  Providers fax number  
Validation:  Must be a valid fax number. 
Remarks:  This is the fax number of the provider.  
Requirement:  None 
 
Data Element:  Provider Type 
Definition:  1=Billing/pricing provider number (Assigned by MAC or NSC).  
    2=Referring/ordering provider (UPIN) 
    3=Performing/rendering provider (Assigned by MAC or NSC)  
    4=Entity is both billing/pricing and performing/rendering provider  
    5=Entity is both referring/ordering and performing/rendering provider  
    6=Entity is all (billing/pricing AND referring/ordering AND 
        performing/rendering provider)  
    7=Billing/pricing provider number (NPI)  
    8=Referring/ordering provider (NPI)  
    9=Performing/rendering provider (NPI) 
    10=Entity is both billing/pricing and performing/rendering provider  
          (NPI)        
11=Entity is both referring/ordering and performing/rendering provider 
      (NPI)        
    12=Entity is all (billing/pricing AND referring/ordering AND 
          performing/rendering provider) (NPI)  
     
Validation:  Must be a valid provider type. 
Remarks:  This field indicates for which provider number associated with a 
sampled claim the address information is furnished. 
Requirement:  Required 
 
Data Element:  Address Order 
Definition:      The order in which the records of provider addresses for the provider are  
  entered into the provider address file detailed record.  This field in   
  combination with the Contractor ID, Provider number, and Provider.     Type 
will make each record in the file unique. 
Validation:  Must be a valid number between 01 and 99 
Remarks:  This field indicated the order in which records containing the addresses 
 for a provider are entered into the detail file.  For instance, if there are 
 three addresses for a provider, the record for the first address for that  provider 
with contain an 01 in this field; and the record for the second address for that 
provider will contain a 02 in this field. 
Requirement:  Required 
 
Data Element:  Provider Address Type 
Definition:  The type of Provider Address furnished.  
Validation:  1 = Practice Address (MCS) 
          Provider address (VMS)  
    2 = Pay To Address (MCS) 
          Payee Address (VMS)  
    3 = Billing Address (VMS) 
    4 = Correspondence Address  
    5 = Medical Record Address 
Remarks:  The first address type for each provider will always be a 1.    
  Subsequent occurrences of addresses for the same provider will have the  
  address type to correspond to the address submitted.  When your files     contain 
only one address for the provider, submit only one provider     address record.  
Submit additional address records for a single provider     number only when your files 
contain   addresses that differ from the  
    Master or Legal address. 
  Correspondence AddressThe Correspondence Address as indicated   on the 
855.  This is the address and telephone number where  
  Medicare can directly get in touch with the enrolling provider.  This  
  address cannot be that of the billing agency, management service  
  organization, or staffing company. 
  Medical Record Addressthe Location of Patients Medical Records   as 
indicated on the 855.  This information is required if the Patients   Medical 
Records are stored at a location other than the Master  
  Address (practice location).  Post Office Boxes and Drop Boxes are   not 
  acceptable as the physical address where patients medical   records are 
  maintained 
Requirement:   Required 
 
Data Element:  Provider E-Mail Address  
Definition:  Providers e-mail address  
     
Validation:  Must be a valid e-mail address  
Remarks:  N/A 
Requirement:  Required if available 
 
Data Element:  Provider Federal Tax Number or EIN 
Definition:  The number assigned to the provider by the Federal government for tax  
  report purposes.  The Federal Tax Number is also known as a tax    
  identification number (TIN) or employer identification number (EIN). 
Validation:  Must be present.  
Remarks:  N/A 
Requirement:  Required for all provider numbers. 
 
Data Element:  Provider Taxonomy Code 
Definition:  The non-medical data code set used to classify health care providers  
  according to provider type or practitioner specialty in an electronic   
  environment, specifically within the American National Standards   
  Institute Accredited Standards Committee health care transaction. 
Validation:  Must be present 
Remarks:  If multiple taxonomy codes are available, furnish the first one listed.  
Requirement:  Required if available 
 
Data Element:  Provider License Number 
Definition:  The professional business license required to provide health care services.  
Validation:  Must be present 
Remarks:  N/A 
Requirement:  Required if available 
 
Data Element:  Provider License State 
Definition:  Identify the state that issued the providers professional business license.  
Validation:  Must be a valid 2 digit state abbreviation as defined by the United States  
  Postal Service (USPS). 
Remarks:  N/A 
Requirement:  Required if available. 
 
Data Element:  Filler 
Definition:  Additional space TBD.  
Validation:  N/A 
Remarks:  N/A  
Requirement:  N/A 
 
Claims Provider Address File 
Claims Provider Address Trailer Record (one record per file) 
 
Field Name  Picture  From  Thru  Initialization 
Contractor ID  X(5)  1  5  Spaces 
Record Type  X(1)  6  6  3 
Record Version Code  X(1)  7  7  Spaces 
Contractor Type  X(1)  8  8  Spaces 
Number of Records  9(9)  9  17  Zeroes 
 
     
DATA ELEMENT DETAIL 
 
Data Element:  Contractor ID 
Definition:        Contractors CMS assigned number.  
Validation:        Must be a valid CMS contractor ID.  
Remarks:    N/A 
Requirement:    Required 
NOTE:     For A/B MAC (B): When multiple workloads share a single processing  
      environment, the Contractor ID will reflect the contractor ID of the       
primary workload. 
 
Data Element:  Record Type 
Definition:  Code indicating type of record.  
Validation:  N/A 
Remarks:  3 = Trailer Record  
Requirement:  Required 
 
Data Element:  Record Version Code 
Definition:  The code indicating the record version of the Provider Address file.  
Validation:  Provider Address files prior to 7/1/2007 did not contain this field. 
    Codes: 
    B = Record Format as of 7/1/2007  
    C = Record Format as of 1/1/2010 
Remarks:  N/A  
Requirement:  Required 
 
Data Element:  Contractor Type  
Definition:  Type of Medicare Contractor.  
Validation:  Must be B or D 
Remarks:  B = A/B MAC (B) 
    D = DME MAC 
Requirement:  Required 
 
Data Element:  Number of Records 
Definition:  Number of provider records on this file. 
Validation:  Must be equal to the number of provider records on the file.  
Remarks:  Do not count header or trailer records. 
Requirement:  Required 
 
Exhibit 37 - Office of Inspector General, Office of Investigations Data Use 
Agreement 
(Rev. 176, Issued: 11-24-06, Effective: 12-26-06, Implementation: 12-26-06) 
 
DUA #:                      
                                 (to be completed by CMS Staff) 
 
OFFICE OF INSPECTOR GENERAL, OFFICE OF INVESTIGATIONS DATA USE 
AGREEMENT 
 
I,              , representing the Office of Inspector General (OIG), Office of  
     
Investigations (OI), will observe the following in the use of the Centers for Medicare & Medicaid Services (CMS) files 
released to me: 
 
A. Purpose:                      
 
  B. The following CMS data file(s) is/are covered under this Agreement.  
Description of Data/File  Year(s)  System of Record  
(to be completed by CMS Staff) 
                    
                    
                    
 
1.  The files will be used only for purposes authorized by the Inspector General Act of 1978 or other applicable law. 
 
2.  No information in the files released to the OIG will be used or disclosed except in strict accordance with all applicable 
confidentiality laws and regulations. Where practicable and consistent with OIG oversight responsibilities, the OIG will 
notify CMS of files extracted or derived from these files are disclosed pursuant to Federal disclosure and 
confidentiality laws. 
 
3.  The information sought in this request is required to be produced to the Office of Investigations pursuant to the 
Inspector General Act 1978, U.S.C. App.  The information is also sought by the OIG in its capacity as a health 
oversight agency, and this information is necessary to further health oversight activities. Disclosure is therefore 
permitted under the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of 
Individually Identifiable Health Information, 45 C.F.R. 164.501; 164.512(a); and 164.512(d). 
     
    4.           will be designated as custodian of these files and will be 
       responsible for establishment and maintenance of security arrangements to prevent unauthorized use.  If the 
custodianship is transferred within the organization, CMS will be notified. 
 
5.   No listings or information from individual records, with identifiers will be published or otherwise released outside of 
those deemed appropriate by OIG to perform the legal scope of OIG duties and responsibilities. 
 
6.  The OIG needs to retain these files for up to 10 years.  CMS will contact the OIG representative at the end of 5 years to 
confirm either that data will be destroyed or that OIG has a continuing need for the data.  CMS will document its 
tracking system to indicate OIGs need for retention or destruction. 
 
OIG Representative- Printed:  Phone Number:  Email Address: 
                      
Street Address:  City:  State:  Zip Code: 
                           
   
Signature:  Date:       
Name of Custodian of Files, If Different:  Phone Number:  E-mail Address: 
                    
Street Address:  City:  State:  Zip Code: 
                           
 
CMS Representative- Printed:       
   
Signature:  Date:        
 
 
38 - Qualified Independent Contractor (QIC) Jurisdictions (as of March 2005 
(Rev. 118, Issued:  08-12-05; Effective/Implementation:  09-12-05) 
 
     
Task Order  Contractor  Covered States 
 
Colorado, New Mexico, Texas, Oklahoma, Arkansas, 
Louisiana, Mississippi, Alabama, Georgia, Florida, 
Tennessee, South Carolina, North Carolina, Virginia, West 
Part A EAST 
Maximus, Inc.  Virginia, Puerto Rico, Virgin Islands, Maine, Vermont, New 
QIC 
Hampshire, Massachusetts, Rhode Island, Connecticut, New 
Jersey, New York, Delaware, Maryland, Pennsylvania, 
Washington DC 
 
 
Washington, Idaho, Montana, North Dakota, South Dakota, 
First Coast  Iowa, Missouri, Kansas, Nebraska, Wyoming, Utah, 
Part A WEST  Service  Arizona, Nevada, California, Alaska, Hawaii, Oregon, 
QIC  Options, Inc.  Kentucky, Ohio, Indiana, Illinois, Minnesota, Michigan, 
(FCSO)  Wisconsin, Guam, Northern Mariana Islands, American 
Samoa 
 
Administrative 
Q2A  N/A-Administrative QIC does not process reconsiderations. 
QIC (AD QIC) 
 
     
Exhibit 39 - Carrier Record Requirements 
(Rev. 141, Issued:  02-24-06; Effective/Implementation:  N/A) 
 
Carrier Record Requirements 
 
Field                 M.D.s/D.O.s   Other Doctor's 
Number        Item            Record              Record 
 
 1. Record Code            Required  Required 
 2. Record Status            Required  Required 
 3. Last Name              Required  Required 
 4 First Name              Required  Required 
 5. Middle Name/Initial          Required  Required 
 6. Name Suffix            Required  Required 
 7. Street (Billing Address)          Required  Required 
 8. City (Billing Address)          Required  Required 
 9. State (Billing Address)          Required  Required 
10. ZIP Code (Billing Address/ show 9 digits)    Required  Required 
11. Street (Business Address)         Required  Required 
12. City (Business Address)          Required  Required 
13. State (Business Address)         Required  Required 
14. ZIP Code (Business Address/ show 9 digits)     Required  Required 
15. State Licensed In            Required  Required 
16. Physician/Health Care Practitioner State License number Required  Required 
17. Date of Birth            Required  Required 
18. Medical School Graduated        Required  Required 
19. Medical School Year Graduated        Required  Required 
20. Date of Death            If Available  If Available 
21. Credentials            Required  Required 
22. Primary Specialty Code          Required  Required 
23. Primary Board Certification Indicator      If Available  If Available 
24. Secondary Specialty Code         If Available  If Available 
25. Secondary Board Certification Indicator    If Available  If Available 
26. Type of Sanction Code          If Available  If Available 
27. Effective Date of Sanction          If Available  If Available 
28. Number of Sanctioned Years        If Available  If Available 
29. Deactivate Resident/Intern Practice/Opt Out code  Required  Required 
30. Group Practice Indicator          Required  Required 
31. Physician/Health Care Practitioner Participation Required  Required 
Indicator 
32. Tax Identification Number        Required  Required 
33. Carrier Provider Number         Required  Required 
34 Registry's Assigned UPIN         N/A    N/A 
35. NHIC Number            N/A    N/A 
36. Incoming Carrier Number       Required  Required 
37. Registry Assigned Error Codes/ Notification Codes  Required  Required 
38. Record Validation Field          N/A    N/A  
39. Special Processing Indicator        N/A    N/A 
40. Special Processing Data          N/A    N/A 
     
41. Individual Social Security Number Required *      N/A    Required 
42. Filler 
 
N/A = Not Applicable on initial data submission 
* Health Care Practitioners Only 
 
     
Exhibit 40 - UPIN Carrier Record Layout 
(Rev. 141, Issued:  02-24-06; Effective/Implementation:  N/A) 
 
UPIN CARRIER RECORD LAYOUT 
Fld.  Position  No.  Item  Description  Comments 
No.  of 
Cols. 
           
1.  001  1  Record Code   1 = Add   
9  2 = Add Develop/Return 
3 = Assigned UPIN 
4 = Registry Usage 
5 = MPIER Update 
6 = Update Develop/Return 
7 = Notifications 
           
2.  002  1  Record Status   1 = Medical Doctor   
9  2 = Other Doctor 
3 = Non Physician/ 
Practitioner 
4 = Group Practice 
           
3.  003-022  20  Last Name  Physician/Health Care  Left justify 
X(20)  Practitioner's Professional  Use Fields 3, 4, 5, and 6 
Last Name. Valid Characters  for group name 
A-Z and Blanks. 
           
4.  023-036  14  First Name  Physician/Practitioner's   Left justify 
X(14)  Professional First Name. 
Valid Characters A-Z and  
Blank. 
           
5.  037-042  6  Middle  Physician/Health Care  Left justify 
Name/Initial  Practitioner's  
X(06)  Professional Middle 
Name or Initial. Valid 
Characters 
A-Z and Blank 
           
6.  043-045  3  X(03)  Name Suffix.  Physician/Health Care 
Practitioners  Left justify 
Name Suffix 
Example:  JR, SR, III.. 
Valid Characters  
A-Z and Blank. 
           
7.  046-070  25  Street  Billing Street  Left justify 
X(25)  Address 
           
 
NOTE: For "9" numeric fields, show zeroes if blank.  For all "X" alpha numeric fields, if no info leave 
field blank 
     
Fld.  Position  No.  Item  Description  Comments 
No.  of 
Cols. 
           
8.  071-085  15  City  City of Billing Address  Left justify 
X(15) 
           
9.  086-087  2  State  State of Billing Address  Standard U.S. post office State  
X(02)  abbreviations. 
           
10.  088-096  9  ZIP Code  ZIP Code of Billing Address  Must report 9 position zip code 
9(09) 
           
11.  097-121  25  Street  Business Street Address  Left justify 
X(25)  The practice or physical 
site address. 
           
12.  122-136  15  City  City of Business Address  Left justify 
X(15) 
           
13.  137-138  2  State  State of Business Address  Standard U.S. post office State  
X(02)  abbreviations. 
           
14.  139-147  9  ZIP Code  ZIP Code of Business  Must report 9 position zip 
9(09)  Address  code. 
           
15.  148-149  2  State  State in which the  Standard U.S. post office State  
Licensed or  physician/Health Care  abbreviations. 
operating in  Practitioner is Licensed or 
X (02)  This Practice Setting. 
           
16.  150-161  12  Physician/  The State License Number or  Right justify and precede with 
Health Care   Registration Number for this  zeroes. 
Practitioner   Practice Setting. 
State License/ 
Registration 
Number X (12) 
           
17.  162-169  8  Date of Birth  (MMDDYYYY) 
** 
9(08) 
           
18.  169-173  5  Medical  Medical School Code  Refer to Exhibit 3. 
School  
Graduated 
Code 
X(05) 
           
19.  174-177  4  Medical  (YYYY)  Year  of Graduation 
School 
Year 
Graduated 
9(04) 
           
     
Fld.  Position  No.  Item  Description  Comments 
No.  of 
Cols. 
           
20.  178-185  8  Date of  (MMDDYYYY) 
Death  ** 
9(08) 
           
21.  186-188  3  Credentials    MD= Medical Doctor 
X (03) 
DO=Doctor of Osteopathy 
CH=Chiropractor 
DDM=Doctor of Dental 
Medicine 
DDS=Doctor of Dental Surgery 
DPM=Podiatrist 
OD= Doctor of Optometry 
CSW=Clinical Social Worker 
PT=Physical Therapist 
CP=Clinical Psychologist 
CNA=Certified Nurse 
Anesthetist 
AA= Anesthesia Assistant 
NP= Nurse Practitioner 
OT= Occupational Therapist 
GRP= Group Practice (USE 
ONLY WITH RECORD 
STATUS 5) 
RNA=Certified Registered 
Nurse Anesthetist 
PSY=Psychologist 
PA= Physician Assistant 
RN= Registered Nurse 
LPN= Licensed Practical Nurse 
CNM= Certified Nurse Midwife 
MSC=Mammography Screening 
Center 
AMB=Ambulance Service 
Supplier 
IDF=Independent Diagnostic 
Screening facility 
CNS = Clinical Nurse Specialist 
AU= Audiologist 
PXS= Portable X-Ray Supplier 
IPL=Independent Physiological 
Laboratory 
           
22.  189-190  2  Primary  Specialty  Code   
Specialty  Code Specified in Part 4 of 
9(02)  MCM 2207 
           
23.  191  1  Primary  Y or N or U for Unknown   
Board 
Certification  
Indicator 
X(01) 
     
Fld.  Position  No.  Item  Description  Comments 
No.  of 
Cols. 
24.  192-193  2  Secondary  Secondary Specialty Code   
Specialty  For This Practice Setting. 
Code  
9(02) 
           
25.  194  1  Secondary  Y=Yes   
Board  N = No 
Certification  U = Unknown 
Indicator  
X(01) 
           
26.  195  1  Type of  Refer to Exhibit 4   
Sanction 
Code 
X(01) 
           
27.  196-199  4  Effective  (MMYY) Windowing   
Date of 
Sanction 
9(06) 
           
28.  200-201  2  Number of  Length of Sanction 01-99   
Sanctioned 
Yrs  
9(02) 
           
29.  202  1  Deactivate  D=Deactivate   
Resident/Inte R =Resident 
rn Practice  I =Intern 
Code  P =Practice 
X(01)  O =OPT Out 
           
30.  203  1  Group  1=Group   
Practice  4 =Solo 
Indicator  
9(01) 
           
31.  204  1  Physician/  Y=Yes  The participation   
Health Care  N=No decision is the latest 
Practitioner/ recorded. 
Group 
Practice 
Participation 
Indicator 
X(01) 
           
32.  205-218  14  Tax  Any number   
Identification  Number you assigned which 
Employer  permits Identifying cross-
Identification  referencing Records For 
no. X(14)  One Individual 
           
33.  219-232  14  Carrier    The number you have provided 
Provider  the Physician/Practitioner for 
Number  billing Medicare 
X(14) 
(Use UPIN 
for Record 
Status 5 only) 
           
Fld.  Position  No.  Item  Description  Comments 
No.  of 
Cols. 
     
34.  233-238  6  Registry's  Leave blank  This space reserved for UPIN 
Number the  assignment 
Assigned 
UPIN 
Registry 
X(06) 
           
35.  239-248  10  NHIC  Exception Turnaround  Assigned by Registry and 
Number  Numbering  correction process 
9(10) 
           
36.  249-253  5  Incoming  CMS Contractor Number;   
Carrier  Multi-state Contractor Use 
Number  The Distinct Number of 
9(05)  Each Jurisdiction. 
           
37.  254-268  15  Registry  Leave blank  Used for Registry error 
Assigned  resolution/auto notification 
Error Codes 
Or 
Notification 
Codes X(15) 
           
38.  269  1  Record  Y=Yes  Indicate that you have validated 
Validation  N=No  the record with State Licensure 
Field X(1)  Board 
           
39.  270  1  Special    Used to indicate special 
Processing  processing record is being 
X(1)  submitted. 
        Acceptable Values:  Record Code "1" with UPIN 
Y = Indicates additional   
settings being added.  Record Code 5 OLD LAST 
1 = Indicates change to  NAME in Field 
Providers Name. 
           
40.  271-290  20  Special    Used to cross check the change 
Processing  to a Providers name or Provider 
Data X(20)  Number. 
           
      Name  Include the Providers LAST  Record Code "5" Providers 
Change  name only as it appears on  NEW name in Fields 3, 4, 5, 6. 
the MPIER prior to the  UPIN Field 34. 
change. 
           
      Provider  Include the Carrier assigned  Record Code "5" includes the 
Number  Number as it appears on the  NEW provider Number in Field 
Change  MPIER prior to the change.  33 UPIN in Field 34. 
           
      Individual  Physician/Health Care  Record returned To you will 
Social  Practitioner Personal SSN  contain the 10 Digit UPIN 
Security 
Number 
           
41.  292-301  10  10 X(10)  Physician/Health Care  Record will contain 
Practitioner/Group   10-digit UPIN 
           
42  302-306  5  5 Digit  Filler  Return record 
X(5) 
 
NOTE:   For "9" numeric fields, show zeroes if blank.  For all "X" alpha numeric fields, if no 
information leave field blank. 
     
40.1 - Trailer Record Data Elements 
(Rev. 141, Issued:  02-24-06; Effective/Implementation:  N/A) 
 
 
           
Fld.    No. of       
No.  Position  Cols.  Item  Description  Comments 
           
1.  001  1  Record Code  9 = Trailer Record   
9(01) 
           
2.  002-006  5  Incoming    CMS Contractor Number; 
Carrier  Multistate Contractors Use 
Number 9(05)  The Distinct Number Of 
Each Jurisdiction 
           
3.  007-014  6  File  (MMDDYYYY) Month,   
Creation9(06)   Day, And Year Of File 
Creation. 
           
4.  015-029  15  Number of  Total Number Of Records  Right justified and precede 
Records Sent  On The File. Do Not  with zeroes. 
9(15)  Include The Trailer 
Record. 
           
5.  030-306  273  Filler X(277)     
 
 
NOTE:  For "9" numeric fields, show zeroes if blank.  For all "X" alpha numeric fields, if no information 
leave field blank. 
     
Exhibit 41.1 - List of Medical School in the U.S. 
(Rev. 141, Issued:  02-24-06; Effective/Implementation:  N/A) 
 
LIST OF MEDICAL SCHOOLS IN THE U.S. 
 
ALABAMA 
00102 University of Alabama School of Medicine, Birmingham, AL 3529  
00104  Birmingham Medical College 
00106  University of South Alabama College of Medicine, Mobile, AL 37788 
 
ARIZONA 
00301  University of Arizona College of Medicine, Tucson, AZ 85724 
 
ARKANSAS 
00401 University of Arkansas College of Medicine, Little Rock, AR 77205 
00402  College of Physicians and Surgeons, Little Rock, AR 77205 
 
CALIFORNIA 
00501  Cooper Medical College, San Francisco, CA 94143 
00502  University of California, San Francisco School of Medicine, San Francisco, CA 94143 
00504  California Eclectic Medical College, Los Angeles, CA 90033 
00505  Hahneman Medical College of the Pacific, San Francisco, CA 94305 
 
00506  University of Southern California School of Medicine, Los Angeles, CA 90033 
00507  College of Physicians and Surgeons of San Francisco, CA 
00508  Oakland College of Medicine and Surgery 
00509  College of Physicians and Surgeons, Los Angeles, CA 90024 
00511  Stanford University School of Medicine, Palo Alto, CA 94305 
00512  Loma Linda University School of Medicine, Loma Linda, CA 92350 
00513  Pacific Medical College, Los Angeles 
00514  University of California, UCLA School of Medicine, Los Angeles, CA 90024 
00515  University of California, California College of Medicine, Irvine, CA 92717 
00516  University of California, Irvine, California College of Medicine Irvine, CA 92717 
00517  University of California, Irvine, California College of Medicine, Irvine, CA 92717 
00518  University of California, San Diego School of Medicine, La Jolla, CA 92093 
00519  University of California, Davis School of Medicine, Davis, CA 95616 
00576  College of Osteo of the Pacific,  Pomona, CA 91766 
 
COLORADO 
00702  University of Colorado School of Medicine, Denver, CO 80262 
00705  Denver and Gross College of Medicine Denver, CO 80262 
 
CONNECTICUT 
00801  Yale University School of Medicine, New Haven, CT 06510 
00802 University of Connecticut School of Medicine, Farmington, CT 06032 
 
DISTRICT OF COLUMBIA  
01001  George Washington University School of Medicine, Washington, DC 20037 
01002  Georgetown University School of Medicine, Washington, DC 20007 
     
01003  Howard University College of Medicine, Washington, DC 20059 
 
FLORIDA 
01102  University of Miami School of Medicine, Miami, FL 33101 
01103  University of Florida College of Medicine, Gainesville, FL 32610 
01104  University of South Florida College of Medicine, Tampa, FL 33612 
01175  Southeastern College of Osteo Medicine, Miami, FL 33162 
 
GEORGIA 
01201  Medical College of Georgia, Augusta, GA 30912 
01205  Emory University School of Medicine, Atlanta, GA 30322 
01209  Georgia College of Eclectric Medicine and Surgery, Atlanta, GA 30314 
01211  Atlanta College of Physicians and Surgeons, Atlanta, GA 30322 
01212  Atlanta School of Medicine Atlanta, GA 31207 
01218  Hospital Medical College Eclectric, Atlanta, GA 31207 
01219  Southern College of Medicine and Surgery, Atlanta, GA 30314 
01221  Morehouse School of Medicine, Atlanta, GA 31207 
01222  Mercer University School of Medicine, Macon, GA 31207 
 
HAWAII 
01401  University of Hawaii John A. Burns School of Medicine, Honolulu, HI 96822  
 
ILLINOIS 
01601  Rush Medical College of Rush University, Chicago, IL 60612 
01602  University of Chicago, Pritzker School of Medicine, Chicago, IL 60637 
01604  The Hahneman Medical College and Hospital, Chicago, IL 60637 
01605  College of Medicine and Surgery, Chicago, IL 60658 
01606  Northwestern University Medical School, Chicago, IL 60611 
01608  Bennett Medical College, Chicago, IL 60639 
01609  Northwestern University Women Medical School, Chicago, IL 60637 
01610  Chicago Homeopathic Medical College, Chicago, IL 60612 
01611  University of Illinois at Chicago Health Science Center, Chicago, IL 60612 
01613  Harvey Medical College, Chicago, IL 60637 
01614  National Medical University, Chicago 60639 
01615  Hering Medical College, Chicago, IL 60638 
 
ILLINOIS 
01616  Jenner Medical College, Chicago, IL 60637 
01617  Illinois Medical College, Chicago, IL 60637 
01618  Dunham Medical College, Chicago, IL 60637 
01619  American Medical Missionary College, Battle Creek, Chicago, IL 60637 
01622  Chicago College of Medicine and Surgery 
01623  Dearborn Medical College, Chicago, IL 60637 
01642  University of Health Sciences/ Chicago Medical School, North Chicago, IL 60064 
01643  Loyola University of Chicago, Stitch School of Medicine, Maywood, IL 60153 
01644  The General Medical College, Chicago, IL 60615 
01645  Southern Illinois University School of Medicine, Springfield, IL 62708 
01675  Chicago College of Osteopathy, Chicago, IL 60615 
 
     
INDIANA 
01705  Physiological Medical College of Indiana, Indianapolis, IN 46202 
01708  Medical College of Indiana, Indianapolis, IN 46224 
01709  Central College of Physicians and Surgeons, Indianapolis, IN 46223 
01717  Eclectic Medical College of Indiana, Indianapolis, IN 46224 
01718  Indiana Medical College, Indianapolis, IN 46224 
 
INDIANA 
01719  School of Medicine of Purdue University, Indianapolis, IN 46202 
01720  Indiana University School of Medicine, Indianapolis, IN 4622  
 
IOWA 
01801  College of Physicians and Surgeons, Keokuk, IA 52632 
01803  University of Iowa College of Medicine, Iowa City, IA 52242 
01804  State University of Iowa College of Homeopathic Medicine, Iowa City, IA 52242 
01806 Drake University College of Medicine, Des Moines, IA 50311 
01808 Sioux City College of Medicine, Sioux City, IA 50312 
01810  Keokuk Medical College, College of Physicians and Surgeons, Keokuk, IA 52632 
01875  University of Osteopathic Medicine and Health Sciences, Des Moines, IA 50312 
 
KANSAS 
01902  University of Kansas School of Medicine, Kansas City, KS 66103  
01903  Kansas Medical College, Topeka, KS 66606  
01904  College of Physicians and Surgeons, Kansas City, KS 66110  
01907  Western Eclectic College of Medicine and Surgery, Kansas City, KS 66102  
 
KENTUCKY 
02001  Kentucky School of Medicine, Louisville, KY 40292 
02002  University of Louisville School of Medicine, Louisville, KY 40292 
02004  Louisville Medical College, Louisville, KY 40292 
02005  Hospital College of Medicine, Louisville, KY 
 
KENTUCKY 
02006  Louisville National Medical College, Louisville, KY 40292 
02008  Southwestern Homeopathic Medical College and Hospital, Louisville, KY 40546 
02009  Kentucky University Medical Department,  Louisville, KY 40292 
02011  Louisville Hospital Medical College, Louisville, KY 40292 
02012  University of Kentucky College of Medicine Lexington, KY 40536 
 
LOUISIANA 
02101  Tulane University School of Medicine,  New Orleans, LA 70112 
02104  Flint Medical College of New Orleans University, New Orleans, LA 70112  
02105  Louisiana State University School of Medicine in New Orleans, New Orleans, LA 70112 
02106  Louisiana State University School of Medicine in Shreveport, Shreveport, LA 71130 
 
MAINE 
02201  Bowdoin Medical School, Brunswick-Portland ME 04003 
02275  University of New England, College of Osteo Medicine, Biddeford, ME 04005 
 
     
MARYLAND 
02301  University of Maryland School of Medicine, Baltimore, MD 21201 
02303  College of Physicians and Surgeons of Baltimore, Baltimore, MD 21201 
02304  Baltimore Medical College, Baltimore, MD 21201 
02305  Womans Medical College of Baltimore, Baltimore, MD 21201 
02306  Baltimore University School of Medicine, Baltimore, MD 21201 
02307  Johns Hopkins University School of Medicine, Baltimore, MD 21205 
02308  Atlantic Medical College, Baltimore, MD 21201 
02309  Maryland Medical College, Baltimore, MD 21201 
02311  Maryland College of Eclectic Medicine and Surgery, Baltimore, MD 21201 
02312  Uniformed Services University of the Health Sciences, Bethesda, MD 20014 
 
MASSACHUSETTS 
02401  Harvard Medical School, Boston, MA 02115 
02405  Boston University School of Medicine, Boston, MA 02118 
02406  College of Physicians and Surgeons, Boston, MA 02111 
02407  Tufts University School of Medicine, Boston, MA 02111 
02415  Middlesex University School of Medicine, Waltham, MA 02154 
02416  University of Massachusetts Medical School,  Worcester, MA 01605 
 
MICHIGAN 
02501  University of Michigan Medical School, Ann Arbor, MI 48109 
02505  University of Michigan Homeopathic Medical School, Ann Arbor, MI 48209 
02507  Wayne State University School of Medicine, Detroit, MI 48201 
02508  Michigan College of Medicine and Surgery, Detroit, MI 48201 
02512  Michigan State University College of Human Medicine, East Lansing, MI 48824 
02576  Michigan State University College of Osteopathic Medicine, East Lansing, MI 48824 
 
MINNESOTA 
02604  University of Minnesota Medical School, Minneapolis, MN 55455 
02605  Minneapolis College of Physicians and Surgeons 
02607  University of Minnesota, Duluth School of Medicine, Duluth, MN 55812 
02608  Mayo Medical School, Rochester, MN 55905 
 
MISSISSIPPI  
02701  University of Mississippi School of Medicine, Jackson, MS 39216 
02702  Mississippi Medical College, Meridian, MS 39305 
 
MISSOURI 
02801  Missouri Medical College, St. Louis, MO 63110 
02802  Washington University School of Medicine, St Louis, MO 63110 
02803  University of Missouri, Columbia School of Medicine, Columbia, MO 65212 
02805  Homeopathic Medical College of Missouri, St. Louis, MO 63141 
02807  St. Louis College of Physicians and Surgeons 
02808  Kansas City Medical College 
02810  National University of Arts and Sciences Medical Department, St. Louis, MO 63110 
02820  University Medical College of Kansas City Kansas City, MO 64111 
02822  Ensworth Medical College, St. Joseph, MO 64507 
02826  Kansas City Homeopathic Medical College 
     
02828  Barnes Medical College, St. Louis, MO 63110 
02830  Woman's Medical College, Kansas City, MO 63111 
02833  Eclectic Medical University, Kansas City, MO 63111 
02834  Saint Louis University School of Medicine, St Louis, MO 63104 
02835  Southwest School of Medicine and Hospital, Kansas City, MO 63111 
02843  Kansas City College of Medicine and Surgery 
02844  Kansas City University of Physicians and Surgeons 
02845  Mid West Medical College, Kansas City, MO (See 02843) 
02846  University of Missouri, Kansas City School of Medicine, Kansas City, MO 64108 
02878  The University of Health Sciences, College of Osteo Medicine, Kansas City, MO 64124 
02879  Kirksville College of Osteopathic Medicine, Kirksville, MO 63501 
 
NEBRASKA 
03004  Lincoln Medical College, Eclectic, Lincoln, NE 68501 
03005  University of Nebraska College of Medicine, Omaha, NE 68105 
03006  Creighton University School of Medicine, Omaha, NE 68178 
03007  Nebraska College of Medicine, Lincoln, NE 69508 
 
NEVADA 
03101  University of Nevada School of Medicine, Reno, NV 89507 
 
NEW HAMPSHIRE 
03201  Dartmouth Medical School, Hanover, NH 03756 
 
NEW JERSEY 
03305  UMDNJ-New Jersey Medical School, Newark, NJ 07103 
03306  UMDNJ-Robert Wood Johnson Medical School, Piscataway, NJ 08854 
03375  UMDNJ New Jersey School of Osteo Medicine, Camden, NJ 08103 
 
NEW MEXICO 
03401  University of New Mexico School of Medicine, Albuquerque, NM 87131 
 
NEW YORK 
03501  Columbia University College of Physicians and Surgeons, New York, NY 10032 
03503  Albany Medical College of Union University, Albany, NY 12208 
03506  State Univesity of New York at Buffalo School of  Medicine, Buffalo, NY 14214 
03508  State University of New York Downstate Medical Center, Brooklyn, NY 12203 
03509  New York Medical College, Valhalla, NY 10595 
03510  Bellevue Hospital Medical College, New York, NY 10016 
03511  New York Medical College and Hospital for Women, New York 10025 
03513  Eclectic Medical College of the City of New York 
03515  State University of New York Health Science Center of Syracuse, Syracuse, NY 13210 
03519  New York University School of Medicine, New York, NY 10016 
03520  Cornell University Medical College, New York, NY 10021 
03543   Fordham University School of Medicine, New York, NY 10027 
03545  University of Rochester School of Medicine and Dentistry, Rochester, NY 14642  
03546  Albert Einstein College of Medicine of Yeshiva University, New York, NY 10461 
03547  Mount Sinai School of Medicine of City University of New York, New York NY 10029 
     
03548  State University of New York at Stony Brook, School of Medicine, Stony Brook, NY 
11794 
03575  New York College of Osteo Medicine of New York Institute of Technology, Old 
Westbury, NY 11568 
 
NORTH CAROLINA 
03601  University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27514 
03603  Leonard Medical School, Raleigh, NC 27604 
03604  North Carolina Medical College, Charlotte, NC 28223 
03605  Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC 
27103 
03607  Duke University School of Medicine, Durham, NC 27710 
03608  East Carolina University School of Medicine, Greenville, NC 27834 
 
NORTH DAKOTA 
03701  University of North Dakota School of Medicine, Grand Forks, ND 58201 
 
OHIO 
03801  Medical College of Ohio, Cincinnati, OH 44115 
03802  Eclectic Medical College, Cincinnati, OH 44115 
03803  Starling Medical College, Columbus, OH 45210 
03806  Case Western Reserve University School of Medicine, Cleveland, OH 44206  
03808  Cincinnati College of Medicine and Surgery 
03809  Miami Medical College, Cincinnati, OH 44106 
03811  University of Wooster Medical Department, Cleveland, OH 44206 
03819  Toledo Medical College 
03823  Cleveland Medical College, Homeopathic Cleveland, OH 45210 
03825  Ohio Medical University Columbus, OH 45210 
03826  Cleveland Pulte Medical College 
03840  Ohio State University College of Medicine, Columbus, OH 43210 
03841  University of Cincinnati College of Medicine, Cincinnati, OH 45267 
03843  Medical College of Ohio at Toledo, Toledo, OH 43699 
03844  Northeastern Ohio Universities College of Medicine, Rootstown, OH 44272 
03845  Wright State University School of Medicine, Dayton, OH 45401 
03875  Ohio University of Osteo Medicine, Athens, OH 45701 
 
OKLAHOMA 
03901  University of Oklahoma College of Medicine, Oklahoma City, OK 73190 
03905  Oral Roberts University School of Medicine, Tulsa, OK 74171 
03979  Oklahoma College of Osteopathic Medicine and Surgery, Tulsa, OK 47127 
 
OREGON 
04001  Williamette University Medical Department, Salem, OR 97304 
04002  Oregon Health Sciences University School of Medicine, Portland, OR 97201 
 
PENNSYLVANIA 
04101  University of Pennsylvania School of Medicine, Philadelphia, PA 19104 
04102  Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA 19107 
04107  Medical College of Pennsylvania, Philadelphia, PA 19129 
     
04109  Hahnemann University College of Medicine, Philadelphia, PA 19102 
04111  Medico Chirurgical College of Philadelphia, Philadelphia, PA 19102 
04112  University of Pittsburgh School of Medicine, Pittsburgh, PA 15261 
04113  Temple University School of Medicine, Philadelphia, PA 19140 
04114  Pennsylvania State University College of Medicine, Hershey, PA 17033 
04177  Philadelphia College of Osteopathic Medicine, Philadelphia, PA 191431 
 
PUERTO RICO 
04201  University of Puerto Rico School of Medicine, San Juan, PR 00936 
04202  Ponce School of Medicine, Ponce, PR 00732 
04203  Universidad Central del Caribe Escuela de Medicina, Cayey, PR 00633 
04204  University De Ciencias Med San Juan Bautista, Hato Rey, PR 00917 
 
RHODE ISLAND 
04301  Brown University Program in Medicine, Providence, RI 02912 
 
SOUTH CAROLINA 
04501  Medical University of South Carolina College of Medicine, Charleston, SC 29425 
04504  University of South Carolina School of Medicine, Columbia, SC 29208 
 
SOUTH DAKOTA 
04601  University of South Dakota School of Medicine, Vermillion, SD 57069 
 
TENNESSEE 
04701  University of Nashville Medical Department 
04705  Vanderbilt University School of Medicine, Nashville, TN 37232 
04706  University of Tennessee College of Medicine, Memphis, TN 38163 
04707  Meharry Medical College School of Medicine, Nashville, TN 37208 
04708  Memphis Hospital Medical College 
04709  Chattanooga Medical College 
04710  Lincoln Memorial University Medical Department, Knoxville, TN 37920 
04711  University of the South Medical Department, Sewanee, TN 37375 
04713  Knoxville Medical College 
04714  University of West Tennessee College of Medicine and Surgery, Memphis, TN 37402 
04715  College of Physicians and Surgeons, Memphis, TN 37208  
04720  East Tennessee State University, Quillen-Dishner College of Medicine, Johnson City, TN 
37614 
 
TEXAS 
04802  University of Texas Medical Branch at Galveston, Galveston, TX 77550 
04803  Fort Worth School of Medicine 
04804  Baylor College of Medicine, Houston, TX 77030 
04805  Physiological Medical College of Texas, Dallas, TX 76203 
04806  Southern Methodist University Medical Department, Dallas, TX 
04807  Gate City Medical College, Dallas, TX 76204 
04812  University of Texas Southwestern Medical School at Dallas, Dallas, TX 75235 
04813  University of Texas Medical School at San Antonio, San Antonio, TX 78284 
04814  University of Texas Medical School at Houston, Houston, TX 77225 
04815  Texas Tech University Health Science Center School of Medicine, Lubbock, TX 79430 
     
04816  Texas A & M University College of Medicine, College Station, TX 77843 
04878  Texas College of Osteopathic Medicine, Lubbock, TX 79430 
 
UTAH 
04901  University of Utah School of Medicine, Salt Lake City, UT 84132 
 
VERMONT 
05002  University of Vermont College of Medicine, Burlington, VT 05405 
 
VIRGINIA 
05101  University of Virginia School of Medicine, Charlottesville, VA 22908 
05104  Medical College of Virginia Commonwealth University School of Medicine, Virginia, 
Richmond, VA 23298 
05106  University College of Medicine, Richmond, VA 23298 
05107  Eastern Virginia Medical School, Norfolk, VA 23501 
 
WASHINGTON  
05404  University of Washington School of Medicine, Seattle, WA 98195 
05415  Washington College of Physicians and Surgeons, Seattle, WA  98196  
 
WEST VIRGINIA 
05501  West Virginia University School of Medicine, Morgantown, WV 26506 
05502  Marshall University School Medicine, Huntington, WV 25701 
05575  West Virginia School of Osteopathic Medicine, Lewisburg, WV 24901 
 
WISCONSIN 
05602 Wisconsin College of Physicians and Surgeons, Milwaukee, WI 53226 
05603  Milwaukee Medical College 
05605  University of Wisconsin Medical School, Madison, WI 53706 
05606  Medical College of Wisconsin, Milwaukee, WI 53226 
 
This list of codes for medical schools in the U.S. is copyrighted by the American Medical 
Association.  Carrier use is restricted to CMS requirements in the physician identification effort. 
 
Copyright 1987 
American Medical Association 
535 North Dearborn Street 
Chicago, IL 60610 
All Rights Reserved 
Additional copies 
may be purchased from: 
Book & Pamphlet Fulfillment OP-167/7 
American Medical Association 
P.O. Box 10946 
Chicago, IL 60610 
HNA: 86-818:33M:2/87 
USBN 0-89970-237-6 
ISSN 0892-0109 
     
Exhibit 41.2 - Directory of Podiatric Medical Colleges 
(Rev. 141, Issued:  02-24-06; Effective/Implementation:  N/A) 
 
DIRECTORY OF PODIATRIC MEDICAL COLLEGES 
 
30000               California College of Podiatric Medicine 
    1210 Scott St., San Francisco, CA  94120 
 
30100               Dr. William M. Scholl School of College of Podiatric Medicine 
    1001 North Dearborn St., Chicago, IL  60610 
 
30200               New York College of Podiatric Medicine 
53 East 124th St., New York, NY  10035 
 
30300              Ohio College of Podiatric Medicine  
    10515 Carnegie Ave., Cleveland, OH  44106 
 
30400              Pennsylvania College of Podiatric Medicine 
Eighth at Rale St, Philadelphia, PA  19107 
 
30500              Barry University School of Podiatric Medicine 
    11300 Northeast Second Ave., Miami Shores, FL 33161 
 
30600              College of Podiatric Medicine and Surgery, 
University of Osteopathic Medicine and Health Sciences 
    3200 Grand Ave., Des Moines, IA  50312 
 
     
Exhibit 41.3 - American Optometric Association Council on Optometric 
Education 
(Rev. 141, Issued:  02-24-06; Effective/Implementation:  N/A) 
 
List of Accredited Professional Optometric Degree Programs 
June 1986 
 
40000 University of Alabama in Birmingham 
School of Optometry 
Birmingham, AL  35292 
 
40010 University of California 
School of Optometry 
Minor Hall 
Berkley, Ca  94720 
 
40020  Ferris State College 
College of Optometry 
Big Rapids, MI  49307 
AMERICAN OPTOMETRIC ASSOCIATION 
COUNCIL ON OPTOMETRIC EDUCATION 
 
40030 University of Houston 
College of Optometry 
Houston, TX  77004 
40040  Illinois College of Optometry 
3241 South Michigan Avenue  
Chicago, IL  60616 
 
40050  Indiana University 
School of Optometry 
Bloomington, IN 47405 
  
40060 Inter-American University of Puerto Rico 
School of Optometry 
San Juan, PR  00936 
 
40070 University of Missouri 
St. Louis, MO  63121 
 
40080 University of Montreal 
School of Optometry 
Montreal, P.Q. 
Canada H3C 3J7 
 
40090 New England 
College of Optometry 
Boston, MA  02115 
 
     
40100  Berkeley Northeastern State University 
College of Optometry 
Tahlequah, Ok  74464 
 
40110  State University of NY 
State College of Optometry 
New York, NY  10010 
 
40120  The Ohio State University 
College of Optometry 
Columbus, OH  43210 
 
40130  Pacific University 
College of Optometry 
Forest Grove, OR  97116 
 
40140  Pennsylvania College of Optometry 
Philadelphia, PA  19141 
 
40150  South California College of Optometry 
Fullerton, CA  96231 
40160  Southern College of Optometry 
Memphis, TN  38104 
 
40170  University of Waterloo 
School of Optometry 
Waterloo, Ontario 
Canada N2L 3G1 
 
     
Exhibit 41.4 - List of Chiropractic Schools in the U.S. 
(Rev. 141, Issued:  02-24-06; Effective/Implementation:  N/A) 
 
List of Chiropractic Schools in the U.S 
 
Code 
 
50010    Adio Institute of Straight Chiropractic 
Levittown, PA 19056 
Changed name to Pennsylvania College of Straight Chiropractic - (1984) 
 
50020    Atlantic States Chiropractic Institute 
Brooklyn, NY 10021 
Merged with Columbia Institute of Chiropractic 
 
50030   Bebout College of Chiropractic 
Indianapolis, IN 46224 
 
50040    Booker T. Washington Chiropractic College 
Kansas City, MO 66103 50050 
 
50050    Logan College 
Oklahoma City, OK 73190 
Formerly Carver-Denny Chiropractic 
College Merged with Logan College of Chiropractic - (1958)  
 
50060    Los Angeles College of Chiropractic 
Formerly California Chiropractic College 
(1963)  Los Angeles, CA 90024 
 
50065   Central States College of Physiatrics and 
Chiropractic Eaton, OH  45320  
 
50070    Canadian Memorial Chiropractic College 
Toronto, Ontario M4G 3E6 50080  
 
50080   Chiropractic Institute of New York 
New York, NY 10022  
 
50090   Crisco Chiropractic College (Proposed) 
Crisco, TX 77650 
 
* Schools in business since 1950 
**Schools not listed use code 5000 
 
     
50100   Cleveland Chiropractic College 
Los Angeles, CA  90004 
 
50110   Cleveland Chiropractic College 
Kansas City, MO 64131 
 
50120   Columbia College of Chiropractic 
Baltimore, MD 21201 
 
50130   Columbia College of Chiropractic 
Alameda, CA 94501 
 
50140   Columbia College of Chiropractic 
and Naturopathy Sacramento, CA 95860 
 
50150   Columbia Institute of Chiropractic 
New York, NY 10025 
 
50160   Hollywood College of Chiropractic 
Hollywood, CA 90024 
 
50170   Lafayette Institute 
Philadelphia, PA 19104 
 
50180   Life Chiropractic College 
San Lorenzo, CA 94580 
 
50190   Lincoln Chiropractic College 
Marietta, GA 30060 
 
50200   Reaver School of Chiropractic 
Dayton, OH 45401 
 
50210   Restview Chiropractic College 
University of Chiropractic 
    Seattle, WA  98196 
 
50220    San Francisco College of Chiropractic 
San Francisco, CA  94128 
    Formerly West Coast Chiropractic 
    College; Name changed to Metropolitan 
    College of Chiropractic - 1944 
50230    Sherman College of Straight Chiropractic, Spartanburg, SC 29304 
50240    Western States College of Chiropractic, Portland, OR 97230 
50250    University of Pasadena, College of Chiropractic, Pasadena, CA 91108 
50260    University of Natural Healing Arts, Denver CO 80262 
50270    National College of Chiropractic, Lombard IL 60148 
50280    New York Chiropractic College, Glen Head, NY 11545 
50290    Northwestern College of Chiropractic, Bloomington, MN 55431 
     
50300    Palmer College of Chiropractic  West, Sunnyvale, CA 94087 
50310    Palmer College of Chiropractic, Davenport, IA 52803  
     
Exhibit 42 - Sanction Codes 
(Rev. 141, Issued:  02-24-06; Effective/Implementation:  N/A) 
 
Sanction Codes * 
 
CODE     DESCRIPTION 
 
A - 1128(a)(1)  -   Program-related conviction 
B - 1128(a)(2)  -   Conviction for patient abuse or neglect 
C - 1128(b)(1)  -   Conviction relating to fraud 
D - 1128(b)(2)  -    Conviction relating to obstruction of an investigation 
E - 1128(b)(3)  -   Conviction relating to controlled substances 
F - 1128(b)(4)  -   License revocation or suspension 
G - 1128(b)(5)  -    Suspension or exclusion under a Federal or State health care program 
H - 1128(b)(6)  -   (Formerly 1862(d)(1)(B) and (C)) - Excessive claims or furnishing of  
unnecessary or substandard items or services 
I -   1128(b)(7)  -   Fraud, kickbacks and other prohibited activities  
(including 1162(d)(1A)) 
J - 1128(b)(8)  -   (Formerly 1128(b) - Entities owned or controlled by a sanctioned  
individual 
K - 1128(b)(9)   Failure to disclose required information 
L - 1128(b)(10) -   Failure to supply requested information on subcontractors and suppliers 
M -1128(b)(11) -   Failure to provide payment information 
N - 1128(b)(12) -   Failure to grant immediate access 
O - 1128(b)(13) -   Failure to take corrective action 
P - 1128(b)(14) -   Default on health education loan or scholarship obligations 
Q - 1128Aa      -    (Formerly 1128(c) - Imposition of a civil money penalty or assessment 
R - 1156(b)     -   (Formerly 1160) - PRO recommendation 
U -                  -    UNKNOWN (Physician is sanctioned, but type of sanction unknown) 
 
 
* If a physician has more than one sanction, show the code of the sanction with the longest 
duration. 
 
     
Exhibit 43 - Carrier Transmittal Sheet 
(Rev. 141, Issued:  02-24-06; Effective/Implementation:  N/A) 
 
 
______________________________________________________________________  
A.  
UPIN Carrier Data Transmittal  
______________________________________________________________________  
Deliver to:               1.   Carrier Number:  
2. *Name and Address of Carrier  
______________________________________________________________________ 
UPIN Records Included in this Transmittal  
______________________________________________________________________  
3.  Date Prepared:             4.  Date Shipped:  
______________________________________________________________________  
B. 1 UPIN Data Records: Tape Diskette  
Volume Serial Number: ____________________________  
           ____________________________  
          ____________________________  
   ____________________________  
   ____________________________  
   ____________________________  
______________________________________________________________________  
B. 2   Total Records  
______________________________________________________________________  
B. 3   Type Records:  
Medical Doctor/D.O. Records 
Other Doctor Records 
______________________________________________________________________  
C. 1  
We have successfully processed the above file 
(no reel will be returned). 
______________________________________________________________________  
C. 2  
We are unable to accept your UPIN Data Records. 
See below for information on reason for return. 
______________________________________________________________________  
Reason for return:  
______________________________________________________________________ 
 
* Enter complete name and address of persons to whom all questions may be addressed. 
______________________________________________________________________ 
 
     
Exhibit 44 
(Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
 
Standard Core 
Joint Operating Agreement 
Between 
RACs and UPICs 
 
   Recovery Audit Contractors (RACs) 
        Unified Program Integrity Contractors (UPICs) 
 
Revision History Log 
Version  Date  Changed By  Description of Change  Approval 
Required 
V01         
V02         
 
     
Table of Contents 
 
1.  Introduction                   275 
1.1.  Purpose of this JOA........................................................................................ 275 
1.2.  Parties ................................................................................................................. 5 
1.3.  Jurisdictions, Contacts, Roles, and Responsibilities .......................................... 5 
1.4.  Confidentiality ................................................................................................ 275 
1.5.  Liability .......................................................................................................... 275 
1.6.  Funding............................................................................................................... 5 
2.  Document Maintenance              276 
2.1.  Standard Core JOA ......................................................................................... 276 
2.2.  JOA Appendices ............................................................................................. 276 
2.3.  Required Roles ............................................................................................... 276 
2.4.  Managing Change .......................................................................................... 277 
2.5.  Approval of Standard Core JOA .................................................................... 277 
3.  Communication                279 
3.1.  JOA Checkpoint Meetings ............................................................................. 279 
3.2.  Other Workgroup Meetings ........................................................................... 279 
3.3.  Issue Escalation and Resolution Process ........................................................ 279 
3.4.  Non-Compliance ............................................................................................ 280 
3.5.  Communication Regarding CMS Changes .................................................... 280 
4.  Securing Email Information              281 
5.  Identification and Action on Fraudulent Behavior        282 
5.1.  Identification and Notification of Fraud by the RAC ..................................... 282 
5.2.  Coordination with Law Enforcement ............................................................. 282 
5.3.  High Risk Areas ............................................................................................. 282 
6.  Training                  283 
6.1.  Training provided by the UPIC ...................................................................... 283 
 
     
1.  Introduction 
 
1.1.  Purpose of this JOA 
 
This Joint Operating Agreement (JOA) is designed to promote cooperation between Recovery 
Audit Contractors (RACs) and the Unified Program Integrity Contractor (UPIC) by establishing 
and maintaining shared expectations for the interaction among these Parties to the JOA. 
 
1.2.  Parties 
 
Parties to the JOA are identified in Appendix Z. Please see Section 2.5 below in this JOA for 
information regarding completion of this appendix. 
 
1.3.  Jurisdictions, Contacts, Roles, and Responsibilities 
 
This information is provided in Appendices B and C. Section 2.2 below in this JOA describes the 
process for completion of these appendices. Please note that there are multiple tabs in these 
Microsoft (MS) Excel Workbook appendix files to facilitate use of this information. 
 
1.4.  Confidentiality 
 
Given the nature of the work performed by the RAC and the UPIC, information contained within 
this JOA is to be shared only with members of the RAC, UPIC, and CMS teams. 
 
1.5.  Liability 
 
Although both the RAC and UPIC each individually have a contractual relationship with CMS, 
there is no privity of contract between the RAC and the UPIC. 
 
Each contractor will be indemnified and protected by limitations on liability according to the terms 
of its respective contract with CMS. In light of the provisions of each contractors current contracts 
with CMS and the constraints of law, no amendments to their respective contracts are made through 
this JOA with respect to indemnification or limitations on liability. 
 
1.6.  Funding 
 
Nothing in this JOA will obligate any parties to perform any tasks that add significant cost and are 
outside current scope of work unless adequate funding for these tasks is received from CMS. 
 
2.  Document Maintenance 
 
2.1.  Standard Core JOA 
 
The Standard Core JOA is established and maintained by CMS to apply standardized best practices 
for the interaction between the RAC and UPIC contractors. This Standard Core JOA is purposely 
designed so that it does not need to reflect contractor specific information, which is instead 
     
contained in the JOA Appendix Documents. This JOA should not be modified from the standard 
without consulting with the TO COTRs. 
 
2.2.  JOA Appendices 
 
List of Appendices  Appendix A lists all JOA appendices, identifies the name of the team 
responsible for collecting and incorporating updates, and briefly describes how each appendix is to 
be created and maintained. 
 
Distributed Update Responsibilities  Appendix documents are separated to facilitate maintenance. 
 
The Contact List, for example, is divided into separate files by team so that each team can make 
and distribute updates to their list without having to coordinate input from other teams. If a 
contractor holds multiple contracts with CMS and if this contractor wants a separate Contact List 
for each contract to facilitate updates by different teams, this is allowed. The multiple tabs within 
each Contact List Excel Workbook facilitate differentiation between multiple task orders on a 
single contract. 
 
Use Across Multiple JOAs  The templates for these appendix documents, such as the Contact List 
templates, have been formatted so that they can be applied to multiple JOAs, eliminating the need 
to maintain similar/duplicate information across multiple JOAs. 
 
Document Owner  The name of the individual person on each team who will update each 
appendix will be identified by that team at the top of each of their appendix documents. This 
facilitates identification of the person to whom updates should be sent. 
 
Templates  CMS provides a standard template for each appendix which can be amended by each 
party if necessary to effectively convey the information for their team. To promote consistency, 
please apply the standard template to the greatest degree practical. 
 
2.3.  Required Roles 
 
To promote proper direction of communication, each RAC and UPIC will 
identify, in its Contact List, a Primary and an Alternate for each of the following 
Required Roles: 
 
  JOA POC  Joint Operating Agreement Point of Contact  This individual is responsible for 
serving as the lead contractor point of contact in establishing and maintaining the JOA content 
and in leading the resolution of any JOA-related issues that may arise. 
 
  JOA Approver  One individual from the RAC and one individual from the UPIC 
will be identified to approve the JOA. 
 
  Operational Lead  This individual is responsible for serving as the lead point of contact in 
performing ongoing operational work under the terms of the JOA. This standard title is used in 
the JOA because various teams use different titles for the individuals that they have serving in 
this role, and the JOA can not effectively incorporate all of those titles. Each party will identify 
their Operational Lead in their Contact List, and they are welcome to add in the Contact List 
any other appropriate titles for this individual as well. 
     
 
2.4.  Managing Change 
 
Change Suggestions  Recommendations for updates to JOA documents are encouraged and are to 
be sent to the Document Owner. 
 
Revision History  Each Document Owner is to identify changes to JOA documents in the Revision 
History Log. 
 
Version Number  The version number is used to make sure that everyone is looking at the same 
version of a document. The Document Owner is to increment the JOA version number each time 
the JOA is sent out for approval. Multiple updates can be consolidated into the same version 
number. The version number is imbedded as the last characters (ex: V01) of each file name. 
 
Process Note: In MS Excel, updates to the version number in the file name are automatically 
propagated to the top of each printed Excel document. In MS Word, select File, Print Preview 
when the version number in the file name is updated to cause the updated version number to be 
propagated from the file name to the top of the document. 
 
2.5.  Approval of Standard Core JOA 
 
CMS Approval of All Versions of the JOA 
 
  CMS will solicit input, make updates, distribute, and refine this Standard Core JOA as necessary. 
Through this cycle of change, CMS will have reviewed and approved all updates. 
 
RAC and UPIC Approval of the First JOA 
 
  CMS directs that all Parties to the JOA (the RAC and UPIC) are to sign (using hand written 
signature) the first jointly approved version of the JOA. 
 
  To accomplish this, the JOA Approvers are to hand-write their signature on two copies of 
Appendix Z, the JOA Approval Form, which they are then to mail (one copy each) to the 
primary RAC JOA POC and UPIC TO COTR who are responsible for their retention and for 
providing a copy of these upon request. 
 
  To facilitate communication of status, the JOA Approvers are also to send out an email to these 
individuals indicating that they have approved the JOA. 
 
RAC and UPIC Approval of Ongoing Updates 
 
  As CMS makes subsequent updates to the Standard Core JOA, CMS will advise contractors via 
Email if the new version is sufficiently changed to require approval. CMS will also update the 
last column of the Revision History table of the JOA to keep a record of which versions require 
approval. 
 
  A hand written signature is not required for ongoing updates. Instead, an electronic signature 
(an electronic copy of the approvers signature) is to be used as the signature. 
     
 
  To provide approval for ongoing updates, the JOA Approver is to fill out Appendix Z, paste in 
their electronic signature, and then send this completed document via email to the Primary and 
Alternate JOA POC for the RAC and UPIC TO COTR. The Primary JOA POCs and TO 
COTRs are responsible for retaining these emails and for providing a copy of these upon 
request. 
 
No Approval Required on Appendix Updates  No approval is required on updates to the 
appendices. 
 
Timing of Approvals  Parties are to provide approval within 10 business days of receipt of an 
updated Standard Core JOA. If parties have an issue with the JOA, they are to raise this issue 
within 10 business days. If no issues are identified before the end of this period, the JOA updates 
will be considered approved. 
 
Distribution  Each JOA POC will disseminate information regarding the update 
within their organization. 
 
3.  Communication 
 
Communication is a crucial component that will occur at multiple levels using 
multiple tools and techniques as described below. 
 
3.1.  JOA Checkpoint Meetings 
 
Purpose  These meetings provide a forum for communication on topics of mutual interest among 
the Parties to the JOA. Topics will include a discussion of any issues with coordination among the 
parties the status of any changes to the JOA documents. 
 
Location  These meetings will most often take place via conference call. In those instances where a 
RAC and a UPIC are located close enough to allow a short drive, some participants may join in-
person. 
 
Frequency  The meetings will occur at minimum on a quarterly basis for the first year after the 
signing of the first JOA and then at least semi-annually thereafter. 
 
Meeting Dates  CMS representatives need to attend multiple of these meetings across contractors, 
so CMS will work with contractors to coordinate spreading of these meetings over time. At the 
conclusion of each meeting, the participants will determine mutually agreeable timing (and location 
where appropriate) for the next meeting; information that will then be confirmed via email.  
Changes will be communicated through the JOA POC via email. 
 
Facilitation  Responsibility for facilitating the meeting will rotate between the RAC and the UPIC. 
This will include preparation of the agenda, providing a dial in number, facilitating the discussion, 
and capturing and distributing meeting minutes. 
 
Meeting Minutes  Are to be distributed within five business days of the meeting and should clearly 
identify Action Items for review in the next meeting. 
 
     
Participation  Invitees are to minimally include the applicable CMS COTRs and the Primary and 
Alternate JOA POC. The JOA POC will invite other participants as appropriate. 
 
3.2.  Other Workgroup Meetings 
 
Purpose  In addition to the JOA Checkpoint meetings, the Parties to the JOA will interact on a 
regular basis in smaller workgroups to address specific needs. 
 
Location, Timing, and Facilitation Will be similar to the Checkpoint Meetings. 
 
Formation  Recommendations for new workgroups should be considered at the JOA Checkpoint 
Meetings. 
 
3.3.  Issue Escalation and Resolution Process 
 
Issues will be escalated if necessary for resolution via the following process: 
 
1.  Source  The RAC and the UPIC individuals identifying the issue will work with their 
counter-parts first to attempt to resolve the issue. 
 
2.  JOA POCs  If they are unable to come to a resolution, the matter will be brought to the 
attention of the RAC Contractor JOA POC and the UPIC JOA POC (identified in the 
Contractor Contact List Appendices). 
 
3.  Operational Leads  If they are unable to come to a resolution, the matter will be 
escalated to the RAC Operational Lead and the UPIC Operational Lead (identified in the 
Contractor Contact List Appendices). 
 
4.  CMS Contract Officer Technical Representatives (COTRs)  If they are unable to come 
to a resolution, the Operational Leads will bring the matter to the attention of the CMS 
COTRs (identified in the CMS Contact List Appendices). 
 
5.  JOA Alternative Dispute Resolution (ADR) Team  In the event the dispute between the 
RAC and the UPIC cannot be resolved, the issues will be directed in writing to the CMS 
RAC and UPIC Contracting Officers, Project Officers, and COTRs for resolution by the 
JOA ADR) team. The ADR team will issue a written determination to both the RAC and 
the UPIC. 
 
Timing of Issue Escalation and Resolution  The speed with which issues are escalated and 
resolved will be dependent on the priority of the issue, with higher impact issues receiving quicker 
attention by all parties. As a general guideline, parties should endeavor to resolve or escalate an 
issue within 1-3 days of its receipt, or they should reply to all parties to advise them of the reasons 
for additional time needed for action. 
 
3.4.  Non-Compliance 
 
If a party does not comply with a provision of the JOA, notification and resolution will take place 
as follows: 
 
     
1.  Notification  If a party does not comply with a provision of the JOA, the Operational 
Lead for that party will notify the Operational lead for the other party. 
 
2.  Resolution  A non-compliance is often one-time event with no significant impact 
which can often be quickly resolved and prevented in the future through the interaction 
of the Operational Leads. In these circumstances, escalation is not required. 
 
3.  Escalation  If a non-compliance creates an impact that either party feels requires 
escalation either for notification purposes or for issue resolution purposes, then the 
Operational Leads will notify the CMS COTRs. If necessary, the ADR process 
described above will be applied to achieve closure. 
 
3.5.  Communication Regarding CMS Changes 
 
As part of ongoing operations, the RAC and the UPIC Contractor staff will both review documents 
received from CMS, including Transmittals, Program Memoranda, Change Requests and Notes. 
The RAC and the UPIC Contractor will continue to determine their own operational impact and 
will provide comments and escalate issues to CMS independently, as appropriate. 
 
All issues that are determined to have an impact on any RAC or UPIC Contractor operations 
included in this JOA will be submitted to the RAC and UPIC JOA POCs for discussion at the next 
JOA Checkpoint Meeting, or sooner if appropriate. 
 
3.6.  Securing Email Information 
CMS has indicated that it is not appropriate to send emails containing beneficiary or provider 
 identifiers (including names and numbers) even if those identifiers are contained within a password- 
protected attachment.  Each JOA Participant is responsible for obtaining, understanding, 
interpreting, and implementing its own policies and procedures regarding use of email containing 
beneficiary or provider identifiers.  CMS Secure Email may be used to send protected information 
to CMS and other users of this email system. If Secure Email is not available, send this information 
via an encrypted CD through registered mail. 
 
4.  Identification and Action on Fraudulent Behavior 
 
4.1.  Identification and Notification of Fraud by the RAC 
 
RAC Responsibility  When the RAC encounters an issue that meets the criteria of potential fraud, 
the RAC will notify the RAC PO who will forward this to the Director of the Division of Benefit 
Integrity Management Operations. 
 
Indicators of Fraud  The following are indicators of fraud that must be reported to the RAC PO. The 
RAC should use their best judgment to determine if other findings may constitute fraudulent 
behavior. Section 6.2 of this Standard Core JOA provides information regarding training for the RAC 
staff to identify fraud. 
 
  Submission of false claims 
  Services being rendered by unlicensed individuals 
     
  Ordered services being provided without a legitimate physician order 
  Claims for beneficiaries or providers that are deceased 
  Non-compliance with medical record requests 
 
4.2.  Coordination with Law Enforcement 
 
The UPIC will interact with Law Enforcement related to potential fraudulent activity. The RAC 
must not contact Law Enforcement with fraud suspicions; they must contact the RAC PO. Law 
enforcement may contact the RAC with recovery inquiries but any other LE RFIs shall be referred 
by the RAC directly to the UPIC. 
 
4.3.  High Risk Areas 
 
CMS may identify High Risk areas within a UPIC jurisdiction. These are areas that are known to 
have wide-spread fraud. The UPICs are required to take aggressive, rapid and innovative measures 
to curtail fraud in these areas and this may impact the RACs ability to perform audits in these 
areas. The UPIC will have the ability, in High Risk Areas, to suppress providers in order to protect 
the UPIC and Law Enforcements ability to identify, prevent and prosecute fraudulent activities. 
 
5.  Training 
 
5.1.  Training provided by the  
 
 UPIC
Purpose  Fraud detection and awareness training will be provided to assist the RAC in identifying 
fraudulent behavior, including indicators that RAC staff should look for and examples of real fraud 
scenarios. 
 
Audience  This training is designed for members of the RAC team. 
 
Initial and Annual Training  The UPIC will provide this training at the start of working together as 
contractors and on at least an annual basis thereafter. 
 
New Employee Training  The RAC will be responsible to provide this on-going training for new 
RAC employees throughout the year using the materials provided by the UPIC. 
 
Participation Requirement  Training participation is required to at least one session per year to be 
provided by the UPIC. UPICs can rotate the responsibility for training and must avoid duplication 
across contracts. 
 
Training on Changes  Additional training will be provided by the UPIC when substantive changes 
are identified in fraud detection and awareness. 
 
 
 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
Exhibit 44.1 
(Rev. 902, Issued: 09-27-19, Effective: 10-28-19, Implementation: 10-28-19) 
Joint Operating Agreement  
 
 
 
Between 
 
    
XXX 
In its capacity as the Supplemental Medical Review 
Contractor (SMRC) 
 
And 
 
XXX 
In its capacity as the Unified Program 
Integrity Contractor XXX 
 
Prepared by: 
XXX 
 
 
 
 
 
 
Revision History 
Version  Date  Changed By  Description of Change  Signature Required 
         
         
         
         
         
 
     
   
     
Table of Contents 
 
Revision History .......................................................................................................................... 269 
Table of Contents ........................................................................................................................ 271 
1. Introduction ............................................................................................................................. 273 
1.1 Purpose of the Supplemental Medical Review Contractor ............................................... 273 
1.2 Purpose of the SMRC Joint Operating Agreement ........................................................... 273 
1.3 Scope ................................................................................................................................. 273 
1.4 Joint Operating Agreement Participants and Roles........................................................... 273 
1.4.1 Supplemental Medical Review Contractors Role ..................................................... 274 
1.4.2 Unified Program Integrity Contractors Role............................................................. 274 
1.4.3 Centers for Medicare & Medicaid Services Role ..................................................... 275 
1.5 Liability ............................................................................................................................. 275 
1.6 Mutual Confidentiality ...................................................................................................... 275 
1.7 Independent Contractors ................................................................................................... 276 
1.8 Privacy ............................................................................................................................... 276 
1.9 Funding.............................................................................................................................. 276 
2. Communication ....................................................................................................................... 276 
2.1 Contact Information .......................................................................................................... 276 
2.2 Point of Contact Roles....................................................................................................... 276 
2.3 Joint Operating Agreement Meetings ................................. Error! Bookmark not defined. 
2.4 Workgroup Meetings........................................................... Error! Bookmark not defined. 
2.5 Maintenance of the JOA .................................................................................................... 278 
2.6 Dispute Resolution Process ............................................................................................... 278 
2.7 Mailing Information .......................................................................................................... 279 
3. Systems.................................................................................................................................... 279 
3.1 Data Files........................................................................................................................... 279 
3.2 Security.............................................................................................................................. 279 
4. Processes ................................................................................................................................. 279 
4.1 Misdirected Communications ........................................................................................... 279 
4.2 Ad Hoc Reports ................................................................................................................. 280 
4.3 Fraud Referral ................................................................................................................... 280 
4.4 Process Improvement ........................................................................................................ 280 
Appendix A. Master Contact List ............................................................................................... 281 
Table A-1. Supplemental Medical Review Contractor ............. Error! Bookmark not defined. 
Table A-2. Unified Program Integrity Contractor xxx ............................................................ 281 
Table A-3. Centers for Medicare & Medicaid Services .......................................................... 281 
     
Appendix B. JOA Approval Signature Form .............................................................................. 281 
 
 
 
   
     
1. Introduction 
 
1.1-Purpose of the Supplemental Medical Review Contractor 
 
The purpose of the SMRC is to perform and/or provide support for a variety of tasks aimed at 
lowering the improper payment rates and increasing efficiencies of the Medical Review (MR) 
functions primarily for Medicare Fee-for-Service (FFS); other product line analysis is limited and 
may include Medicaid FFS, private and group health insurance lines of business and Prescription 
Drug Plan (Part D).  One of the primary tasks will be conducting large volumes of nationwide MR 
as directed by the Centers for Medicare & Medicaid Services (CMS). The MR will be performed on 
Medicare FFS claims for Part A, Part B, and DMEPOS programs. These medical review activities 
will assess compliance with Medicares coding, coverage, billing, and payment requirements and 
identify claims improperly paid. The SMRC will recommend recoupment and/or adjustment for 
claims identified as improperly paid. Having a centralized MR resource that can perform large 
volume of MR nationally shall allow for a timely and consistent execution of MR review, activities, 
and decisions. The SMRC shall select subject claims, perform research and/or data analysis, and 
conduct reviews in a manner that will minimize provider and supplier burden.  
 
1.2-Purpose of the SMRC Joint Operating Agreement 
 
The purpose of this no-cost Agreement is to set forth the terms and conditions pursuant to which the 
Parties will coordinate efforts to maintain consistency of the Medicare program in accordance with 
the provisions of their respective CMS contract (CMS Contract).  The term of this Agreement 
shall commence on the Effective Date and continue until either Partys CMS Contract expires, or it 
is terminated by either Party upon thirty (30) days written notice to the other Party. 
 
1.3-Scope 
 
This Agreement is intended to serve as a framework for the collaborative measures the Parties will 
take to implement, maintain, and advance their mutually shared goal of preserving the integrity of 
the Medicare program; it is not intended to be a comprehensive description of the Parties working 
relationship.  This Agreement does not create any affirmative duties, rights or legal obligations 
between the Parties, nor does it give any person or entity their successors and permitted assigns, 
any right, remedy or claim in it.   Each Party has a contractual relationship with CMS and each 
party shall be solely responsible to CMS for its performance under this JOA and the terms of this 
Agreement shall not alter or amend a Partys CMS Contract.  If there are any conflicts between the 
terms of this Agreement and a Partys CMS Contract, the terms of the Partys CMS Contract shall 
take precedence.  The terms of this Agreement shall be interpreted so as to resolve any conflict 
between it and a Partys CMS Contract, and, if necessary, this Agreement shall be amended to 
reconcile any unresolved conflict with a Partys CMS Contract. 
 
1.4-Joint Operating Agreement Participants and Roles 
 
The term JOA Participants refers to the SMRC, CMS, and Unified Program Integrity Contractor 
(UPIC). 
 
 
 
 
     
1.4.1-Supplemental Medical Review Contractors Role 
 
The SMRC will perform research and analysis, MR, statistical sampling, and extrapolation. The 
SMRC will specifically include the following activities: 
 
  Perform Medicare Part A and Part B (including DME) post payment MR in accordance with 
CMS instructions including expedited reviews. The list of providers will be sent via secure 
email provided in Section 4.3; 
  For post payment medical review, develop and send a letter for the solicitation of medical 
records and supporting documentation needed to support the claims, when necessary; 
  Perform claim re-reviews for claims reviewed initially by the SMRC; 
  Perform statistical sampling and extrapolation to assess overpayment or potential 
overpayment(s) made on claims; 
  Access the Recovery Auditor Data Warehouse (RDW) prior to selecting claims for review 
to ensure they are not excluded or suppressed; 
  Upload all claim samples identified into the RDW; 
  Review all services in accordance with the applicable statutes, CMS guidelines, and 
coverage requirements; 
  Recommend claim denial for any claim when a provider fails to send medical records or 
supporting documentation; 
  Maintain a tracking system to reflect and identify MR activities for all claims; 
  Ensure coordination of efforts and prevent duplication of activities or interference with an 
existing investigation or corrective action plan; 
  Ensure each MR is conducted by a Registered Nurse (RN); 
  Ensure each coding review is conducted by a Certified Professional Coder (CPC) or 
Certified Coding Specialist (CCS) with an active certification; 
  Ensure records are maintained confidentially in accordance with the Statement of Work 
(SOW) and applicable regulations; 
  Participate in Administrative Law Judge (ALJ) hearings as a participant or party, as 
appropriate, to defend positions or provide testimony; 
  Provide education on eligible claims to providers as requested for those claims reviewed by 
SMRC; and 
  Participate in discussion periods with providers as requested for those claims reviewed by 
SMRC that are eligible for Discussion & Education (D&E). 
 
The SMRC does not have responsibility for: 
 
  Claims processing and adjudication activities; 
  Performing redeterminations related to appealed initial determinations conducted by the 
SMRC; and 
  Cost report audit activities. 
 
1.4.2-Unified Program Integrity Contractors Role 
 
The UPICs role and responsibilities include: 
  Fraud, waste and abuse investigations and program integrity related data analysis; and 
  Pre and post payment claim review for program integrity purposes. 
 
     
1.4.3-Centers for Medicare & Medicaid Services Role 
 
CMS Contracting Officers Representative (COR), Contract Specialist, and Contracting Officer 
have overall responsibility for the SMRC. The Contract Specialist and Contracting Officer, Office 
of Acquisitions and Grants Management (OAGM), in coordination with the COR, are the only 
persons authorized to: 
 
  Enter into and commit or bind the government by contract for supplies and services; 
  Accept nonconforming work or waive any requirement of the contracts; 
  Authorize reimbursement to the contractor for any costs incurred during the performance of 
the contract; and 
  Modify any term or condition of the contract (that is, make any changes in the SOW, 
modify or extend the period of performance, change the delivery schedule). 
 
1.5-Liability 
 
Each Party is indemnified and protected by limitations on liability according to the terms of its 
respective contract with CMS.  
 
Except with respect to a breach of the confidentiality provision set forth in section 1.6 below, titled 
Mutual Confidentiality, this JOA shall not be construed to give rise to any binding obligation, 
rights, duty or liability, of any kind whatsoever, of any Party to this JOA to any other party. 
 
1.6-Mutual Confidentiality 
 
The parties understand, acknowledge and agree that each partys inventions, discoveries, 
proprietary information and trade secrets are of critical importance to its ongoing operations and 
prospects.  During the course of performing services for CMS according to their respective 
contracts, described above, the parties will likely have access to information that is confidential and 
proprietary to the other party.  In addition, each party may create inventions, make discoveries, 
write software or code, develop file layouts, methodologies or processes, and create applications 
during the course of the parties relationship.  
 
Examples of proprietary information and trade secrets include, but are not limited to, discoveries, 
improvements, processes, developments, designs, know-how, data, file layouts, documentation, 
computer programs (including but not limited to all source code for those programs) and formulae. 
 
Each Party agrees to hold the other partys Confidential Information to at least the same level of 
protection against unauthorized disclosure or use as the receiving party normally uses to protect its 
own information of a similar character, but in no event less than reasonable care. 
 
Neither party shall disclose to any person in any manner, either before, during or after the term of 
this JOA, proprietary or trade secret information (as hereafter defined) except to the extent 
necessary for the performance of each partys duties under this JOA, or as required by CMS 
pursuant to each partys contract with CMS, as applicable.  Each party shall not use 
proprietary/trade secret information of the other for any other purpose whatsoever.  Each party 
agrees to cooperate with the other party, and to use its best efforts, to prevent the unauthorized 
disclosure, use or reproduction of any proprietary/trade secret information of the other.  
 
     
Nothing in this Agreement shall prohibit or limit a partys use of information (including, but not 
limited to, ideas, concepts, know-how, techniques, and methodologies) (i) previously known to that 
party, prior to its receipt from the disclosing party, (ii) independently developed without use of the 
Confidential Information, (iii) acquired by it from a third party which was not, to the recipient's 
knowledge, under an obligation to the disclosing party not to disclose such information, or (iv) 
which is or becomes publicly available through no breach of this Agreement by the receiving party.   
 
The obligation to protect Confidential Information shall survive the expiration or termination of this 
JOA. 
 
1.7-Independent Contractors 
 
The parties each recognize and agree that they are independent contractors.  There is no privity of 
contract between these Parties. Nothing contained in this Agreement shall be construed to make any 
party an agent, servant, partner, employee of or joint venture of or with any other party.  No party 
has the right or authority to interfere with or in any manner influence, direct or control the decision-
making process, evaluations, judgments or reviews of any other.  No party shall have any right or 
authority, whether express or implied, to assume or create any obligation, duty, or responsibility 
whatsoever on behalf of any other party. 
 
1.8-Privacy 
 
The parties agree that issues pertaining to the Privacy Act of 1974, and the Health Insurance 
Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable 
Health Information (The Privacy Rule) published in April 2003 are covered by the two 
organizations independent contracts with CMS. 
 
When future privacy regulations are published, the two organizations will review that information 
and address any impact to joint processes in subsequent versions of the JOA. The parties agree that 
issues pertaining to the confidentiality, privacy, and security of Medicare data are covered by the 
two independent contracts with CMS. 
 
1.9 Funding 
 
Nothing in this JOA will obligate either party to perform any tasks that are outside the current scope 
of work, unless CMS directs such tasks and provides adequate funding. 
 
2. Communication 
 
2.1-Contact Information 
 
Contact information for all parties is provided in Appendix A, Master Contact List. 
 
2.2-Point of Contact Roles 
 
To ensure that communication is properly directed, CMS, the UPIC and the SMRC will identify (in 
Appendix A, Master Contact List) representative(s) to serve as: 
 
     
  JOA Point of Contact (POC): Each party will designate a representative responsible for 
serving as the lead company/agency POC in establishing and maintaining the JOA content, 
and in leading resolution of any JOA-related issues that may arise. Additional information 
regarding maintenance of the JOA is included in Section 2.5, Maintenance of the JOA. 
  JOA Signatory: Each party will designate a representative who is responsible for providing 
final approval and signature for updates to the JOA. 
  Information Technology (IT) POC: Each party will designate a representative to act as a 
focal point for the exchange of information relevant to systems configuration, operation, and 
communications. 
 
2.3-Joint Operating Agreement Meetings 
 
The SMRC and UPIC will assess for and discuss any JOA updates during the monthly workgroup 
meetings. The SMRC and UPIC JOA meetings will provide a forum for communication among the 
SMRC and UPIC JOA participants. The SMRC COR and the UPIC COR are to be notified of all 
SMRC and UPIC JOA conference calls since they are optional participants. 
 
2.4-Workgroup Meetings 
 
Workgroups will be formed based on input from JOA Participants to provide focused attention on 
key topics. Changes in participants in the workgroups will not necessitate a change in the JOA. 
These workgroup meetings will take place by conference calls.  
 
SMRC and UPIC Coordination Workgroup: On an ongoing basis, this workgroup will meet at least 
monthly on the same date/time each month to facilitate coordination of activities related, but not 
limited to, workload, re-reviews, discussion and education sessions, overpayments and appeals. In 
addition to this workgroup, representatives may interact, as needed, in smaller workgroups to focus 
on specific areas, such as overpayments and appeals. 
 
Additional Meetings: The SMRC and UPIC JOA POC will schedule additional conference calls as 
requested by the JOA Participants. 
 
Agenda: The SMRC JOA POC will distribute the Agenda to all members by e-mail in advance of 
the next meeting. The SMRC JOA POC will solicit Agenda items from SMRC and UPIC JOA 
participants approximately one week prior to the meeting. The meetings may include (along with 
other agenda items) high-level data analysis findings, statistical reports, recommendations, review 
activities, and action items. 
 
Participation: Workgroup participation will include representation from CMS, the UPIC, and 
SMRC. At minimum, JOA Participants will include the UPIC Operations, UPIC JOA POC, SMRC 
Program Manager (PM), SMRC JOA POC, CMS SMRC COR/ACOR/BFL, and CMS UPIC 
COR/ACOR/BFLs and others as applicable. 
 
JOA Improvements: Continuous improvement of the JOA will be an agenda item for discussion at 
each meeting. Additional information regarding initiating and controlling changes to the JOA is 
described in Section 2.5, Maintenance of the JOA. 
 
Minutes: SMRC will take Minutes during each workgroup meeting and distribute them by  
     
e-mail to all participants within ten business days of the meeting. SMRC will also track all action 
items in the minutes and report on them at each workgroup meeting. 
 
2.5-Maintenance of the JOA 
 
JOA POCs are invited to initiate continuous improvements to the JOA. Any such suggestions will 
be discussed at the next regularly scheduled JOA meeting or through special sessions as necessary. 
 
Change Suggestions: All suggestions are to be sent to the SMRC JOA POC. Within seven business 
days, the SMRC JOA POC will distribute a draft to CMS and the UPIC JOA POCs. Feedback is to 
be provided within seven business days. The SMRC JOA POC will then distribute a final draft to 
CMS and the UPIC JOA POC. If no issues are identified within seven business days, the updates 
will be considered accepted. The SMRC JOA POC will disseminate information regarding the 
updates to CMS and the UPIC JOA POC  annual reviews, 14 business days will be allowed to 
review changes and make updates for the annual JOA reviews. 
 
Tracking Changes: Changes to the JOA are identified in the Change History Log on the second 
page of this document and are controlled by a version number in the upper right corner of each page 
of the document. Changes to the appendices to this document are also controlled by a version 
number in the lower left corner of each appendix. 
 
Signature of JOA: For those changes to the body of the JOA that are determined by the SMRC 
CMS COR and BFLs to be significant (as identified in the Change History Log on the second page 
of this document), new approvals will be collected. Approvals are not necessary for changes to the 
appendices (such as the Appendix A, Master Contact List). Approval of the first JOA will adhere to 
the following procedure: All parties to the JOA are to sign the first jointly approved version of the 
JOA and subsequent changes using Appendix B, Joint Operating Agreement Approval Signature 
Form. Such signed documents will be distributed to the relevant POCs for the parties identified in 
Appendix A, Master Contact List. 
 
2.6-Dispute Resolution Process 
 
Disputes/issues will be escalated, if necessary, for resolution by the following process: 
 
1.  The SMRC and the UPIC counterparts will first attempt to resolve the issue. 
2.  If the SMRC and the UPIC counterparts are unable to come to a resolution, the matter will 
be brought to the attention of the SMRC JOA POC and the UPIC JOA POC (as identified in 
Appendix A, Master Contact List). 
3.  If the SMRC JOA POC and the UPIC JOA POC are unable to come to a resolution, the 
matter will be escalated to the SMRC PM and the UPIC Project Manager (as identified in 
Appendix A, Master Contact List). 
4.  If the SMRC PM and the UPIC Project Manager are unable to come to a resolution, the 
SMRC PM will bring this matter to the attention of the SMRC CMS COR and the UPIC 
Project Manager will bring this matter to the attention of the UPIC CMS COR (as identified 
in Appendix A, Master Contact List). 
5.  If the dispute between the SMRC and the UPIC cannot be resolved, the issues will be 
directed, in writing, to the CMS CORs and BFLs for resolution by a JOA Alternative 
Dispute Resolution Team. 
 
     
2.7-Mailing Information 
 
All information mailed between the UPIC and SMRC will be sent by delivery service (FedEx, 
United Parcel Service of America [UPS], or DHL Worldwide Express [DHL]) and shipped to 
the addresses specified below: 
 
UPIC Company Name 
Attn: Department 
Mailing Address 
City, State Zip Code 
 
The sender will e-mail the intended recipient a confirmation e-mail containing an inventory of the 
shipment contents, encryption information (if applicable), and tracking number of the package. The 
recipient will confirm receipt of the package upon arrival. Refer to Section 3.2, Systems, regarding 
security. 
 
3. Systems 
 
3.1-Data Files 
 
The CMS has directed the SMRC to perform data analysis activities to support MR and 
overpayment extrapolation. These activities will require the SMRC to obtain data from various 
resources, including, but not limited to, CMS One Program Integrity (One PI) Shared Systems 
database, CMS National Claims History (NCH) database, and RDW. If data is needed from the 
UPICs, this will be discussed during the workgroup meeting. 
 
3.2-Security 
 
Each party agrees to adhere to the security requirements in the Business Partner System Security 
Manual (BPSSM). Both parties agree to work together on all aspects of security in the BPSSM, or 
as otherwise issued via Technical Direction Letter or other means by CMS, that require the joint 
cooperation of both parties. Mail and email exchanges containing Personally Identifiable 
Information (PII) will follow the requirements as outlined by the most current version of the ARS 
which states the PII must be secured in an attachment that has been zipped using FIPS 140-2 
validated software (i.e. SecureZip). Each party further agrees to adhere to CMS JSM/TDL-09323 
and CMS JSM/TDL-11141: Guidelines for Implementing the Centers for Medicare & Medicaid 
Services (CMS) Revised Information Security Incident Handling and Breach Analysis/Notification 
Procedures. 
 
4. Processes 
 
4.1-Misdirected Communications 
 
Misdirected communications may include written, e-mail, or facsimile inquiries received from 
providers. Unless otherwise addressed in this JOA, any misdirected communications will be 
forwarded to the appropriate party (SMRC or UPIC) following the process outlined in Section 2.7 
Mailing Information. 
 
4.2-Collaboration  
     
 
The SMRC will send the UPIC file of providers/suppliers on review via email at xxxx@xxxxxx.xx 
 
4.3-Ad Hoc Reports 
 
Ad hoc reports may be requested by either the UPIC or SMRC via the Ad Hoc Request Form 
(Appendix C xxx). The completed form must be faxed or emailed to the appropriate JOA POC. All 
requests will be evaluated by the receiving contractor for approval based upon feasibility and cost 
of implementation.  The receiving contractor may directly contact the requesting individual to 
clarify data requests as needed. The SMRC and UPIC JOA POCs or authorized individual will 
coordinate with the requestor when these reports are available. 
 
4.4-Fraud Referral 
 
The SMRC will document their findings in a standard format, and, when appropriate, refer the case 
to the Center for Program Integrity (CPI)/Unified Program Integrity Contractor (UPIC) for 
development through the current process in place with CMS. The SMRC will remain accessible to 
the referral agency to facilitate their investigation, and to prepare potential cases for litigation or 
prosecution. SMRC referrals to UPIC xx of potential fraudulent activities should be sent to the 
UPIC xx at: UPICxxLead@admedcorp.com 
 
4.5-Process Improvement 
 
Where appropriate and feasible, the parties will provide recommendations on process refinements. 
Such changes will be presented and approved through the process described in Section 2.5 
regarding changes to the JOA. 
 
     
Appendix A. Master Contact List 
 
Table A-1. Supplemental Medical Review Contractor 
POC Role  Representative  Contact Number  E-mail 
JOA POC       
Project Manager       
MR Director       
Information Security       
Manager 
MR Manager       
Operations Manager       
Liaison, Hearing & Appeals       
Coordinator 
 
Table A-2. Unified Program Integrity Contractor xx 
POC Role  Representative  Contact Number  E-mail 
UPIC JOA POC       
UPIC Operations POC       
UPIC Appeals Manager       
UPIC Appeals Manager       
UPIC Overpayment team       
leaderAudit 
UPIC Overpayment team       
LeaderRecoupment 
UPIC POE Manager       
JOA Signatory       
JOA Signatory       
 
Table A-3. Centers for Medicare & Medicaid Services 
       
SMRC COR       
SMRC ACOR/BFL       
Contracting Officer       
Contracting Specialist       
       
       
       
       
 
Appendix B. JOA Approval Signature Form 
 
Company/Entity Name:   
Signatory Name (Printed):   
Signatory Signature:  ______________________________________________ 
     
Date:  ____/____/____ 
 
 
Company/Entity Name:   
Signatory Name (Printed):   
Signatory Signature:  ______________________________________________ 
Date:  ____/____/____ 
 
 
Company/Entity Name:   
Signatory Name (Printed):   
Signatory Signature:  ______________________________________________ 
Date:  ____/____/____ 
 
 
 
     
Exhibit 45  UPIC Prepayment and Postpayment Notification Letter 
(Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
 
DATE:  UPIC NAME/JURISDICTION: 
PROVIDER NAME:  UPIC CONTACT/PHONE NUMBER: 
PROVIDER ADDRESS:  UPIC ADDRESS:  
PROVIER NUMBER: 
 
Dear Provider Name: 
 
As a Medicare contractor, the Unified Program Integrity Contractor (UPIC) is required by the 
Centers for Medicare & Medicaid Services (CMS) to analyze claims payment data in order to 
identify areas with the greatest risk of inappropriate program payment. Specifically, as a (indicate 
UPIC), (write UPIC Name) is required to investigate situations of potential fraud, waste, and abuse. 
 
Your claims have been selected for a comprehensive medical review of your billing for Medicare 
services pursuant to CMS statutory and regulatory authority. You were selected for this review 
because our analysis of your billing data indicates that there may be aberrancies in your billing. 
 
We have selected claims for services provided during the period   through   . You will 
subsequently receive a request for medical records, which will explain the specific documentation 
that is being requested. If you have any questions regarding the letter requesting medical 
records/documentation, please contact (UPIC Contacts Name) at (Phone Number of UPIC 
Contact). 
 
Thank you for your prompt response to the request for medical records/documentation. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
Exhibit 46.1 - MAC Unified Postpayment ADR Sample Letter 
 (Rev.557, Issued: 11-26-14, Effective: 12-29-14, Implementation: 12-29-14) 
 
 
     
 
Date:  
 
Reference ID:  
Attention:  
Address:    
 
NPI:  
PTAN:  
Phone:  
Fax:  
 
Request Type & Purpose: Notification of Post-payment Probe Review and Request for Medical Records 
Subject: Additional Documentation Required 
 
Dear Medicare Provider/Supplier,  
 
The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce improper 
payment of Medicare claims1. As part of our effort to accomplish this goal, the Medicare 
Administrative Contractor (MAC) program will conduct a post-payment medical review of selected 
Medicare Part A claims.  
 
Reason for Selection 
As an A/B MAC, 'Review Contractor Name' is tasked with preventing inappropriate Medicare 
payments.  This is accomplished through provider education, training, and the medical review of 
claims.  'Review Contractor Name' recently completed review of a sample of service-specific 
claims for HIPPS code XXXXX (1st or 2nd episode with 11 to 13 therapy visits). The calculated 
charge denial rate (CDR) for these claims was 100%.  Refer to the enclosed Encrypted CD for the 
complete list of claims and denial reasons. 
Action: Additional Documentation  
Federal law requires that providers/suppliers submit medical record documentation to support 
claims for Medicare services upon request. Providers/suppliers are required to send supporting 
medical records to the MAC program.  Providing medical records of Medicare patients to the 
MAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA). 
Patient authorization is not required to respond to this request.  
Case ID: 1212121 
 
Patient  Date of  HIC  Date of  Rendering Provider /  Claim  Procedure 
Name  Birth  Number   Service  Supplier  ID  Code 
             
When: mm/dd/yyyy  
Please provide the requested documentation by mm/dd/yyyy.  A response is still required by 
mm/dd/yyyy even if you are unable to locate the requested information. 
 
When the review is completed, you will be notified of the results. The CMS goal is to complete 
the review and deliver the results to providers/suppliers within 60 days of the receipt of all 
medical records needed for the review.   
                                                 
1 Social Security Act Sections 1833(e), 1815(a), and 1842(p)(4) 
     
Consequences  
If the provider/supplier fails to send the requested documentation or contact CMS by 
mm/dd/yyyy, the providers/suppliers Medicare contractor will initiate claims adjustments or 
overpayment recoupment actions for these undocumented services.   
Instructions 
The documentation submitted for this review must be a copy of the patients medical record for each 
encounter clearly identified for each requested beneficiary and the date of service. Providers/suppliers are 
responsible for obtaining supporting documentation from third parties (hospitals, nursing homes, suppliers, 
etc.).  
 
  Refer to the Supporting Documentation attachment for a list of required supporting documentation 
to be submitted. 
  Providers/suppliers must pay the cost of providing this documentation; it cannot be billed to CMS or 
the MAC program.   
  The CMS encourages providers/suppliers to respond quickly.  
  Please do not include Powers of Attorney, Living Wills, or Correspondence. 
  During this review period and at all times, in order to receive payment, providers/suppliers must 
continue to submit claims for all services performed on a beneficiary.  
 
Submission Methods 
Providers/Suppliers may submit this documentation in any of the following ways:  
 
Via postal mail or Encrypted CD/DVD: 
1.  Include a copy of the Post Pay request letter with your documents. 
2.  Complete the ADR Response Cover Sheet Form (enclosed) and place on top of the entire set 
of documents to be submitted. 
a.  An image of the coversheet may be included with the CD/DVD or may be scanned 
as the first image seen within your CD/DVD.  
3.  When submitting responses for multiple claims, please make a copy of the enclosed Part A 
Post Pay ADR Response Separator Sheet and insert between the responses for each 
Document Control Number (DCN).  
4.  If the CD/DVD is password protected, send an email to John.Doe@Company.com and 
Jane.Doe@Company.com and include the package tracking number and password.  
5.  Mail to the following:  
 
Regular Mail:                  Overnight Mail: 
 
Company Name                        Company Name 
Medical Review                           Medical Review 
Mail Code XXXX              OR                  Mail Code XXXX 
Post Office Box XXXXX                     Street Address  
City, State Zip Code                City, State Zip Code 
 
Via fax to: 
1.  XXX-XXX-XXXX  
2.  Include a copy of the ADR letter with your documents. 
3.  Complete the ADR Response Cover Sheet Form (enclosed) and place on top of the entire set 
of documents to be faxed. 
     
4.  When submitting Post Pay ADR responses with multiple claims, make a copy of the 
enclosed Post Pay ADR Response Separator Sheet and insert between the responses for each 
Document Control Number (DCN).   
 
Via Electronic Submission of Medical Documentation (esMD):  
1.  Include a copy of the Post Pay request letter with your documents. 
2.  Complete the ADR Response Cover Sheet Form (enclosed) and place on top of the entire set 
of documents to be sent. 
3.  When submitting Post Pay ADR responses with multiple claims, make a copy of the 
enclosed Post Pay ADR Response Separator Sheet and insert between the responses for each 
Document Control Number (DCN).   
4.  Convert all documents, including your cover sheets, to PDF. 
5.  Submit your documentation to your CONNECT-compatible gateway or HIH. 
6.  More information on esMD can be found at www.cms.gov/esMD 
 
Questions 
If you have any questions please contact XXXXXXXX  at XXX-XXX-XXXX or via postal mail at 
the following:  
 
Company Name 
Street Address 
City, State Zip Code 
 
Sincerely,  
 
A/B MAC Jurisdiction X Medical Review 
 
Attachments / Supplementary Information 
 
1.  Encrypted CD with a listing of claims requiring medical documentation  
2.  Supporting Documentation Required List 
3.  ADR Response Cover Sheet Form 
4.  Separator Sheet Form 
   
     
Exhibit 46.2 - DME MAC Unified Post-Payment ADR Sample Letter 
(Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19) 
 
Letter Date: 
Provider/Supplier Name 
Provider/Supplier 
Address City, State Zip 
 
Case ID #: 
NPI /Provider #: 
PTAN: 
 
Request Type & Purpose: New Request, Post-Payment Claim Review 
Subject: Additional Documentation Required 
Dear Medicare Provider/Supplier, 
The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce improper 
payment of Medicare claims1. As part of our effort to accomplish this goal, the Medicare 
Administrative Contractor (MAC) program will conduct a post-payment medical review of 
selected Medicare DME claims. 
 
Reason for Selection 
 
In the xx quarter 20XX, Suppliers Name HCPCS code XXXXX claim volume was two or 
more standard deviations above the norm when compared to all suppliers billing HCPCS code 
XXXXX in Jurisdiction X. This high claim volume billed by a new supplier for a high dollar 
item is of concern to the DME MAC. 
 
When services appear outside the norm, the DME MAC must verify whether the potential 
error(s) represent an unacceptable practice. The DME MAC is validating this concern by 
performing a post-payment review on ## randomly selected claims billed by Suppliers Name. 
 
ACTION: MEDICAL RECORDS REQUIRED 
 
Federal law requires that providers/suppliers submit medical record documentation to support 
claims for Medicare services upon request. The Centers for Medicare & Medicaid Services DME 
MAC program has randomly selected one or more of your Medicare claims for review, and 
providers/suppliers are required to send supporting medical records when requested. Providing 
medical records of Medicare patients to the MAC program does not violate the Health Insurance 
Portability and Accountability Act (HIPAA). Patient authorization is not required to respond to 
this request. Please refer to the Instructions Section below for a list of supporting documentation 
required. 
 
1Social Security Act Sections 1833 [42 USC 1320c-5 (a) (3)]   
 
     
 
Case ID: XXXXXXX 
 
Patient Name  MBI  Date of Service  Claim ID  Procedure Code 
         
         
         
 
When: MM/DD/YYYY 
 
Please provide the requested documentation by mm/dd/yyyy. A response is still required by 
mm/dd/yyyy even if you are unable to locate the requested information. 
 
Consequences 
 
If the provider/supplier fails to send the requested documentation or contact CMS by 
mm/dd/yyyy, the providers/suppliers Medicare contractor will initiate claims adjustments or 
overpayment recoupment actions for these undocumented services. 
 
Instructions 
 
 Submit supporting documentation from third parties (hospitals, nursing homes, suppliers etc.). 
Providers/suppliers are responsible for obtaining and providing the following documentation: 
o Physicians notes within 30 days of initial date: mm/dd/yyyy 
o Diagnostic Tests 
 Submit the bar coded cover sheet with your submission (optional) 
 Providers/suppliers must pay the cost of providing this documentation; it cannot be billed to 
CMS. 
 
Submission Methods 
 
Providers/suppliers may submit this documentation in any of the following ways: 
 
 Via postal mail to: 
Company Name 
Company Address 
City, State Zip Code 
 
 Via fax to: XXX-XXX-XXXX 
 
 Via Electronic Submission of Medical Documentation (esMD): 
-  More information on esMD can be found at www.cms.gov/esMD 
-  When sending records via esMD, please include a CASE ID number in your file 
transmission 
     
 
 Via Encrypted CD: See attachment for detailed instructions. 
 
Questions 
 
If you have any questions, please contact: 
 
Contact Name 
Department 
Company Name 
Contact Address 
City, State Zip 
Code 
Office: XXX-XXX-XXXX 
Toll Free: XXX-XXX-
XXXX Fax: XXX-XXX-
XXXX 
Company Email 
Address  
Company Website 
 
Sincerely, 
DME MAC Jurisdiction X Medical Review 
 
Attachments / Supplementary Information 
 
1. Important Notices 
2. Cover Sheet 
3. Change of address information 
4. Appeals process 
5. Comparative Data 
6. Encrypted CD Submission Process 
 
   
     
Exhibit 46.3  Recovery Audit Contractor (RAC) Unified Postpayment ADR 
Sample Letter 
(Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19) 
 
Recovery Auditor  
logo 
   
Region X 
RAC 
Date: 
 
Reference ID: 
Attention: 
Address: 
 
NPI: 
PTAN: 
Phone: 
Fax: 
 
Request Type & Purpose: Additional Documentation Required and Request for Medical 
Records 
 
Dear Medicare Provider/Supplier, 
 
The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce the 
improper payment of Medicare claims8 The Recovery Audit Program, mandated by Congress 
has been developed to assist in accomplishing this goal. 
 
Reason for Selection: 
 
Your RAC, (insert name of RAC), is requesting additional documentation for the selected list of 
claims as part of a post-payment complex review approved by CMS. Providers/suppliers will 
receive a Review Results Letter after a claim determination has been made. If an improper 
payment (underpayment or overpayment) is identified, these claims will be sent to your 
Medicare Administrative Contractor (MAC) for adjustment. 
 
Please refer to the enclosed Claims Selected for Review Spreadsheet for a list of selected 
claims. 
 
Action: Additional Documentation 
 
Federal law requires that providers/suppliers submit medical record documentation to 
support claims for Medicare services upon request. Providers/suppliers are required to send 
supporting medical records to (insert RAC name). Providing medical records of Medicare 
     
patients to (insert RAC name) does not violate the Health Insurance Portability and 
Accountability Act (HIPAA). Patient authorization is not required to respond to this request. 
 
When: mm/dd/yyyy 
 
Please provide the requested documentation by mm/dd/yyyy. A response is still required 
by mm/dd/yyyy even if you are unable to locate the requested information. 
 
When the review is complete, you will be notified of the results. (Insert RAC name)s goal is 
to complete the review and deliver the results to providers/suppliers within 30 days of receipt 
of all medical records needed for the review. 
 
Consequences 
 
If the provider/supplier fails to send the requested documentation to (insert RACs name) by 
mm/dd/yyyy, the providers/suppliers MAC will initiate claims adjustments or overpayment 
recoupment actions for these undocumented services. 
 
Instructions 
 
1.  The documentation submitted for this review must be a copy. Do not submit 
original documentation. 
2.  A copy of this additional documentation request letter should be affixed to the 
documentation. Please bundle documents for each claim separately to enable us to 
ensure receipt of all requested documents. 
3.  Providers/suppliers are responsible for obtaining supporting documentation from 
third parties (hospitals, nursing homes, suppliers, etc.). 
4.  Refer to the Supporting Documentation attachment for a list of required 
supporting documentation to be submitted. 
5.  The RAC is required to reimburse providers for the submission of medical records for the 
following claim types:  Acute Care Inpatient Prospective Payment System Hospital 
Claims, Long Term Care Hospital Claims, non-PPS institution, and practitioners. 
6.  If you meet the Medicare definition of one of these provider types, you will be reimbursed 
for the cost of providing copies of the additional documentation. Payment will be issued 
to you within 45 days of receiving the additional documentation. 
7.  For PPS Providers, payment will be in the amount of $0.12 per page, plus the cost of First 
Class postage, if mailed via USPS. For non-PPS Providers and practitioners, payment 
will be in the amount of $0.15 per page, plus the cost of First Class postage, if mailed via 
USPS. The amount per page, for the respective providers, will not exceed this quantity, 
and the maximum payment per medical record, submitted via mail, fax, CD/DVD shall 
not exceed $25.00. For medical records submitted electronically (via esMD), the per 
page amount will be the same as those previously noted. However, the maximum 
payment per medical record shall not exceed $27.00, including a $2.00 transaction fee. 
8.  Please do not include Powers of Attorney, Living Wills, Correspondence, or 
Prior Episodes of Care. 
9.  Requirements for submitting imaged documentation on CD or DVD can be found at 
     
(insert RAC web address) or by calling the RACs Call Center at XXX-XXX-XXXX. 
 
Submission Methods 
 
Providers/suppliers may submit this documentation in any of the following ways: 
 
Via postal mail or Encrypted CD/DVD: 
1. Include a copy of the ADR letter with your documents. 
2. Mail to the following: 
 
 
Regular Mail: 
 
Company Name 
Medical Review 
Mail Code      OR 
Post Office Box 
City, State Zip 
Overnight Mail: 
 
Company Name  
Medical Review  
Mail Code  
Address 
City, State Zip 
     
 
Via fax to: 
1. XXX-XXX-XXXX 
2. Include a copy of the ADR letter with your documents. 
 
Via Electronic Submission of Medical Documentation (esMD): 
1. Include a copy of the ADR letter with your documents. 
2. Submit your documentation to your CONNECT-compatible gateway or HIH. 
3. More information on esMD can be found at www.cms.gov/esMD 
 
Questions 
 
If you have any questions please contact: 
 
Recovery Auditor Audit Contractor Customer Service General Inquiry 
XXX-XXX-XXXX 
Address 
City, State Zip 
    Sincerely, RAC Region X 
 
Attachments / Supplementary Information 
 
1.  Claims Selected for Review Spreadsheet 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
Exhibit 46.4  CERT Unified Post-payment ADR Sample Letter 
(Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19) 
                               
                                
Provider Name 
Address 1 
Address 2 
City ST 00000 
 
Date:  
Reference ID: CID# 
NPI/ Provider #:  
Phone:  
Fax:   
 
Request Type & Purpose: New Request, Post-Payment Claim Review  
Subject: Additional Documentation Required   
 
Dear Medicare Provider/Supplier, 
 
The Centers for Medicare & Medicaid Services (CMS), through the Comprehensive Error Rate 
Testing (CERT) program, carries out the task of requesting, receiving, and reviewing medical 
records1.  The CERT program reviews selected Medicare A, B and DME claims and produces 
annual improper payment rates. For more information regarding the CERT program, please visit 
www.cms.gov/CERT. 
 
Reason for Selection 
 
The CMS CERT program has randomly selected one or more of your Medicare claims for 
review.  
 
Action: Medical Records Required  
 
Federal law requires that providers/suppliers submit medical record documentation to support 
claims for Medicare services upon request.  Providers/suppliers are required to send supporting 
medical records to the CERT program. Providing medical records of Medicare patients to the 
CERT program does not violate the Health Insurance Portability and Accountability Act 
(HIPAA). Patient authorization is not required to respond to this request. Providers/suppliers are 
responsible for obtaining and providing the documentation as identified on the attached Bar 
Coded Cover Sheet. The CMS is not authorized to reimburse providers/suppliers for the cost of 
medical record duplication or mailing. If you use a photocopy service, please ensure that the 
service does not invoice the CERT program. 
 
1Social Security Act Sections 1833 [42 USC 1395l(e)] and 1815 [42 USC 1395g(a)]; 42 CFR 405.980-986 
 
 
     
When: mm/dd/yyyy 
 
Please provide the requested documentation by mm/dd/yyyy.  A response is still required by 
mm/dd/yyyy even if you are unable to locate the requested information. 
 
Consequences  
 
If the provider/supplier fails to send the requested documentation or contact CMS by 
mm/dd/yyyy, the providers/suppliers Medicare contractor will initiate claims adjustments or 
overpayment recoupment actions for these undocumented services. 
 
Instructions  
 
Specific information and instructions pertaining to the sampled claim and returning requested 
documents are shown on the following pages of this letter.   
Please include the bar coded cover sheet with your submission. 
 
Submission Methods 
 
You may submit this documentation in any of the following ways:  
 
  Via postal mail to: 
CERT Documentation Center 
1510 East Parham Road 
Henrico, VA 23228 
     
  Via Fax to: 804-261-8100 or 443-663-2698 
1.  Use the barcoded cover sheet as the only coversheet. 
2.  Do not add your own cover sheetthis slows down the receipt and identification 
process 
3.  Send a separate fax transmission for each individual claim. 
 
  Via Electronic Submission of Medical Documentation (esMD):  
1.  Include a CID# or Claim number and the barcoded cover sheet in your file 
transmission. 
2.   Information on esMD can be found at www.cms.gov/esMD. 
 
  Via CD:  
1.  The images should be encrypted per HIPAA security rules. 
2.  If encrypted, the password and CID# must be provided via 
email to CERTMail@admedcorp.com or via fax to 804-264-
9764. 
3.  Must contain only images in TIFF or PDF format 
 
  Via Email Attachment: 
1.  The email attachment(s) should be encrypted per HIPAA security rules. 
2.  If encrypted, the password and CID# must be provided via phone to 888-779-
7477 or via fax to 804-264-9764. 
3.  Must contain only attachments in TIFF or PDF format. 
     
 
Questions 
 
If you have any questions, please contact: 
 
CERT Documentation Center 
1510 East Parham Road 
Henrico, VA 23228 
 
Office: 443-663-2699 or Toll Free:  888-779-7477 
Fax: 804-261-8100 
 
Sincerely,  
Contact Name 
Director, Payment Accuracy & Reporting Group 
Office of Financial Management 
Centers for Medicare & Medicaid Services 
 
Attachments / Supplementary Information 
 
1.  Claim Information 
2.  Bar Coded Cover Sheet 
 
 
 
   
     
Exhibit 46.5  SMRC Unified Postpayment ADR Sample Letter 
(Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19) 
                                                     
                                      
Letter Date: 
 
Provider/Supplier Name 
Provider/Supplier Address City, 
State Zip 
 
Project ID Number: 
NPI/PROVIDER #: 
PTAN: 
 
Request Type & Purpose: Notification of Post-Payment Claim Review 
Subject: Additional Documentation Required 
Dear Medicare Provider/Supplier, 
The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce improper 
payment of Medicare claims.10 As part of our effort to accomplish this goal, CMS has retained 
Contractor Name as the Supplemental Medical Review Contractor (SMRC) to conduct a 
medical record review of selected Part A and Part B claims. Additional information regarding 
this contract can be found at: website URL. 
 
  Reason for Selection 
 
Reason for Project for XXXX code(s): 
 
  Service on Review - Short Description  
 
This constitutes new and material evidence that establishes good cause for reopening the claim. 
Providing additional documentation for each claim is authorized by CMS and is being 
requested. 
 
  Action: Medical Records Required 
 
10
Federal law  requires that providers/suppliers submit medical record documentation to support 
claims for Medicare services upon request. Providing medical records of Medicare patients to 
the SMRC does not violate the Health Insurance Portability and Accountability Act (HIPAA). 
Patient authorization is not required to respond to this request. 
 
  When: mm/dd/yyyy 
 
Please provide the requested documentation by mm/dd/yyyy. A response is still required by 
mm/dd/yyyy even if you are unable to locate the requested information. Please note, you may 
     
request an extension to submit the requested documentation, if your request is made by 
mm/dd/yyyy. 
 
 
10 Social Security Act Sections [42 USC 1320c-5(a) (3)], 1833 [42 USC 13951 (e)], and 42 CFR 405.980(b) 
 
 
 
 
     
When the review is completed, you will receive a review results letter after a determination has 
been made. The results letter will stipulate if any underpayment(s) or overpayment(s) were 
identified. 
 
  Consequences 
 
If you or your facility fail to send the requested documentation or request an extension by 
mm/dd/yyyy, the Contractor Name will initiate claims adjustments or overpayment 
recoupment actions with your Medicare Administrative Contractor for these undocumented 
services. 
 
  Instructions 
 
 This agency does not reimburse providers/suppliers for the cost associated with copying 
of medical records from any setting. When records are requested, the expense of 
supplying medical records is a part of the administrative costs of doing business with 
Medicare. Therefore, invoices from record retention centers and copying agencies are not 
eligible for reimbursement. 
 Refer to the ADR Claim List for selected claims. 
 A copy of this request letter should be affixed to the documentation submitted. 
 All documentation should be submitted within 45 days of the date of this notice. 
 Please refer to the Submission Methods section below for additional information on 
document preparation and available submission methods. 
 Refer to the enclosed SMRC Response Cover Sheet Form(s) for documentation 
requirements. 
 
 Note: 
 
- Medicare requires that medical record entries for services provided/ordered be 
authenticated by the author. The method used shall be a legible handwritten or 
electronic signature. 
- Stamp signatures are not acceptable. Beneficiary identification, date of service, and 
provider of the service(s) should be clearly identified on the submitted documentation. 
Documentation submitted in response to this request shall comply with these 
requirements. 
- This may require providers/suppliers to contact the hospital or other facility where 
services were provided to obtain signed progress notes, plan of care, discharge 
summary, etc. 
- If signature requirements are not met, the reviewer will conduct the medical review 
without considering the documentation with the missing or illegible signature. This 
could lead the reviewer to determine that medical necessity for the service(s) billed has 
not been substantiated. 
- Contractor name recommends that providers review their documentation prior to 
submission and ensure that all medical record entries and orders are signed 
appropriately. For documentation with a missing, illegible or electronic signature, a 
signature log or signature attestation may be submitted additionally as part of the ADR 
response. For detailed guidance regarding Medicare signature requirements, refer to the 
Medicare Program Integrity Manual, Publication 100-08, Chapter 3 and Section 
3.3.2.4. 
     
 
 
  Submission Methods 
 
Providers/suppliers may submit the documentation in any of the following ways: 
  Include a copy of the Post Pay request letter with your documents. 
  Complete the SMRC Response Cover Sheet Form (enclosed) for each 
claim number requested and place on top of each set of documents to be 
submitted. 
  When submitting Post Pay ADR responses with multiple claims, make a 
copy of the enclosed SMRC Response Cover Sheet Forms and send each 
set of documents separately for each claim number. 
 
  Via fax to: XXX-XXX-XXXX 
  Via Electronic Submission of Medical Documentation (esMD): 
  Convert all documents, including your cover sheets, to PDF. 
  Submit your documentation to your CONNECT-compatible gateway or 
HIH. 
  More information on esMD can be found at www.cms.gov/esMD 
  Via postal mail or Encrypted CD/DVD 
  Image(s)s must be submitted in PDF or multi-page TIF format. 
  If the CD/DVD is password protected, send an email to Email Address. 
Include the Project Number from this letter, the package tracking number 
and password. 
 
Contractor Name and Mailing Address: 
 
 Questions 
 
Thank you for your participation with this review. If you have any questions, please 
contact: 
 
Office: XXX-XXX-XXXX 
 
Sincerely, 
Supplemental Medical Review Contractor Program Manager  
 
  Attachments / Supplementary Information 
 
1.  SMRC Point of Contact Information 
2.  SMRC ADR Claim List 
3.  SMRC Response Cover Sheet Form(s) 
 
 
 
 
     
 
 
Exhibit 47  Program Integrity Unit Contacts within the State 
Medicaid Agency 
 
State  POC  Phone  POC E-mail Address 
(334) 
Jacqueline 
Alabama  242- jacqueline.thomas@medicaid.alabama.gov 
Thomas 
5318 
(907) 
Alaska  Doug Jones  269- doug.jones@alaska.gov 
0361 
(684) 
American  Sandra King 
633- sandrakingyoung@gmail.com  
Samoa  Young 
4818 
(602) 
Sharon 
Arizona  417- Sharon.Ormsby@azahcccs.gov 
Ormsby 
4535 
Elizabeth  (501) 
Arkansas  Thomas  683- Elizabeth.Smith@governor.arkansas.gov  
Smith  6404 
(916) 
California  Bruce Lim  440- bruce.lim@dhcs.ca.gov 
7552 
(303) 
Katherine 
Colorado  866- katherine.quinby@state.co.us 
Quinby 
4940 
(860) 
John 
Connecticut  424- john.mccormick@ct.gov 
McCormick 
5920 
(302) 
Linda 
Delaware  255- linda.murphy@state.de.us 
Murphy 
9801 
(202) 
District of  Donald 
698- Donald.Shearer@dc.gov 
Columbia  Shearer 
2007 
Jennifer  (850) 
Jennifer.Ellinsen@myflorida.com 
Ellingsen  412-
Florida  Fred.Becknell@myflorida.com 
Fred  3977 
 
Becknell 
(404) 
Georgia  Terri Kight  463- tkight@dch.ga.gov  
7437 
Theresa  671-
Guam  Arcangel   735- theresa.arcangel@dphss.guam.gov 
(also SMD)  7282 
     
 
 
State  POC  Phone  POC E-mail Address 
Shelley  (808) 
Hawaii  Siegman  692- ssiegman@medicaid.dhs.state.hi.us  
(Acting)  8095 
(208) 
Idaho  Lori Stiles  334- stilesl@dhw.idaho.gov 
0653 
(217) 
Bradley 
Illinois  524- bradley.hart@illinois.gov  
Hart 
5105 
317-
John 
Indiana  234- John.Mccullough@fssa.IN.gov   
McCullough 
2129 
(515) 
Rocco 
Iowa  256- rrusso@dhs.state.ia.us 
Russo 
4632 
(785) 
Kansas  Krista Engel  296- KEngel@kdheks.gov 
7286 
(502) 
Veronica  564-
Kentucky  Veronica.Cecil@Ky.gov  
Cecil  5472 ext 
2253 
Ruth  (225) 
Kennedy  342- Ruth.Kennedy@la.gov 
Louisiana 
Jen Steele  3032  Jen.Steele@la.gov  
(Deputy) 
(207) 
Herb F. 
Maine  287- Herb.F.downs@maine.gov 
Downs 
2778 
(410) 
Susan 
Maryland  767- Susan.Steinberg@maryland.gov 
Steinberg 
6039 
(617) 
Joan  joan.senatore@state.ma.us 
Massachusetts  348-
Senatore   
5380 
MI Corp   
Michigan  Email  dch-oig@michigan.gov 
Account 
(651) 
Jennifer 
Minnesota  431- jennifer.hasbargen@state.mn.us 
Hasbargen  
4356 
Otis  (601) 
Mississippi  Washington,  576- Otis.Washington@medicaid.ms.gov  
Jr.  4135 
     
 
 
State  POC  Phone  POC E-mail Address 
(573) 
Jessica 
Missouri  751- Jessica.Dresner@dss.mo.gov 
Dresner 
3399 
(406) 
Montana  Michelle  444-
Truax  4120  MTruax@mt.gov 
(402) 
Anne 
Nebraska  471- anne.harvey@nebraska.gov 
Harvey 
1718 
(775) 
Tammy   
Nevada  684-
Moffitt  Tammy.Moffitt@dhcfp.nv.gov 
3623 
(603) 
New  Sherry 
271- sbozoian@dhhs.state.nh.us 
Hampshire  Bozoian 
8029 
(609) 
New Jersey  Elissa Smith  292- Elissa.Smith@osc.state.nj.us 
4350 
(505) 
Everet 
New Mexico  827- everet.apodaca@state.nm.us 
Apodaca 
3135 
Corp. Email   
New York  Bmfa@omig.ny.gov   
Account 
(919) 
North  Rob 
814- Rob.kindsvatter@dhhs.nc.gov  
Carolina  Kindsvatter 
0123 
(701) 
North Dakota  Dawn Mock  328- dmock@nd.gov 
1895 
Northern  670-
Helen 
Mariana  664- chcmc@pticom.com 
Sablan 
Islands  4884 
Rachel  N/A 
Ohio  Rachel.jones@medicaid.ohio.gov 
Jones 
(405) 
Kelly 
Oklahoma  522- Kelly.Shropshire@okhca.org  
Shropshire 
7131 
(503) 
Charles 
Oregon  378- charles.hibner@state.or.us 
Hibner 
8113 
Clint  (717) 
Pennsylvania  Eisenhower        2  1  4  -        ceisenhowe@pa.gov 
(Acting)  1942 
     
 
 
State  POC  Phone  POC E-mail Address 
(787) 
765-
Luz Cruz-
4044 
Romero 
(787)  luz.cruz@salud.pr.gov  
Puerto Rico  Ricardo 
474- raivera@asespr.org  
Rivera 
3300 
Cardona 
ext. 
3003 
(401) 
Bruce 
Rhode Island  462- bruce.mcintyre@ohhs.ri.gov 
McIntyre 
0613 
 
South  Betty Jane  (803)   
Carolina  (BJ) Church  898- church@scdhhs.gov 
2678 
Lori  (605) 
South Dakota  Lawson  773- Lori.Lawson@state.sd.us 
(Interim)  3495 
(615) 
Dennis J 
Tennessee  507- Dennis.J.Garvey@tn.gov  
Garvey 
6696 
(512) 
Stuart 
Texas  491- Stuart.bowen@hhsc.state.tx.us  
Bowen, Jr. 
2051 
(801) 
Noleen 
Utah  538- noleenwarrick@utah.gov 
Warrick 
6455 
     
Ron Clark  (802)  ron.clark@state.vt.us 
(ret.  879- Leanne.miles@state.vt.us 
Vermont  2/20/15)  5652 
Leanne  (802) 
Miles (eff.  879-
2/20/15)  5964 
Renee  (340) 
Virgin Islands  Joseph- 774- Renee.JosephRhymer@dhs.vi.gov  
Rhymer  0930 
(804) 
Virginia  Louis Elie  786- louis.elie@dmas.virginia.gov 
5590 
(360) 
Cathie Ott 
Washington  725- cathie.ott@hca.wa.gov  
(Acting) 
2116 
(304) 
Tammy G. 
West Virginia  356- Tammy.G.Hypes@wv.gov 
Hypes 
4885 
     
 
 
State  POC  Phone  POC E-mail Address 
(608) 
Wisconsin  Alan White  266- alan.white@dhs.wisconsin.gov 
7436 
(307) 
Mark 
Wyoming  777- Mark.gaskill@wyo.gov  
Gaskill 
2054 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
 
Transmittals Issued for this Chapter 
     
 
 
Rev #  Issue Date  Subject  Impl Date  CR# 
R11218PI  01/27/2020  Updates to Chapter 4 in Publication (Pub.)  02/28/2022 12595 
100-08, Including Removal of Requests for 
Anticipated Payment (RAP) Suppressions 
and Updates to Exhibit 16 - Model Payment 
Suspension Letters in Pub. 100-08 
R10910PI  08/10/2021  Updates to Exhibit 16 in Exhibits Chapter  09/13/2021 12385 
of Publication (Pub.) 100-08 
R10383PI. 10/09/2020  Updates to Chapters 4, 5, 8, 15, and Exhibits  11/10/2020 11199 
of Publication (Pub.) 100-08 
R10228PI  07/27/2020  Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8, 10, 08/27/2020 11884 
11, and Exhibits of Publication (Pub.) 100-
08 
R943PI  02/21/2020  Updates to Chapter 4 and Exhibit 8 in  03/24/2020 11629 
Publication (Pub.) 100-08 
R902PI  09/27/2019  Updates to Chapters 3, 4, 8, 15, and  10/28/2019 11425 
Exhibits of Publication (Pub.) 100-08 
R884PI  05/31/2019  Update to Exhibit 46.2, 46.3, 46.4, and 46.5 08/30/2019 11242 
in Publication (Pub.) 100-08 
R867PI  02/22/2019  Update to Exhibit 16 - Model Payment  03/25/2019 11088 
Suspension Letters in Publication (Pub.) 
100-08 
R863PI  02/12/2019  Local Coverage Determinations (LCDs  01/08/2019 10901 
R857PI  01/30/2019  Local Coverage Determinations (LCDs)  01/08/2019 10901 
R854PI  01/11/2019  Local Coverage Determinations (LCDs)  01/08/2019 10901 
R829PI  10/03/2018  Local Coverage Determinations (LCDs)  01/08/2019 10901 
R831PI  10/01/2018  Update to Exhibit 16 - Model Payment  10/01/2018 10849 
Suspension Letters in Publication (Pub.) 
100-08 
R826PI  09/21/2018  Update to Chapter 4, Section 4.18.1.4 and  10/22/2018 10853 
Exhibit 16 in Publication (Pub.) 100-08 
R823PI  08/31/2018  Update to Exhibit 16 - Model Payment  10/01/2018 10849 
Suspension Letters in Publication (Pub.) 
100-08- Rescinded and replaced by 
Transmittal 831 
R780PI  03/16/2018  Update to Exhibit 16 - Model Payment  05/16/2018 10498 
Suspension Letters in Pub. 100-08 
R726PI  06/16/2017  Comprehensive Error Rate Testing (CERT)  10/02/2017 9835 
File Layout for Social Security Number 
Removal Initiative (SSNRI) 
     
 
 
R714PI  05/12/2017  Comprehensive Error Rate Testing (CERT)  10/02/2017 9835 
File Layout for Social Security Number 
Removal Initiative (SSNRI)  Rescinded 
and replaced by Transmittal 726 
R675PI  09/09/2016  Update to Chapter 4, Pub. 100-08  12/12/2016 9426 
R670PI  08/19/2016  Update of Payment Suspension Instructions  11/23/2016 9396 
R660PI  06/29/2016  Comprehensive Error Rate Testing (CERT)  07/05/2016 9238 
program Treatment of Claims in the Prior 
Authorization Model 
R637PI  02/05/2016  Comprehensive Error Rate Testing (CERT)  07/05/2016 9238 
program Treatment of Claims in the Prior 
Authorization Model  Rescinded and 
replaced by Transmittal 660 
R617PI  10/09/2015  Update to Chapter 3 of Pub. 100-08  11/10/2015 9303 
R558PI  11/26/2014  Update to the Program Integrity Manual  12/29/2014 8859 
(Pub. 100-08) Exhibit 36 - Overview of the 
Comprehensive Error Rate Testing (CERT) 
Process 
R557PI  11/26/2014  Update to CMS Publication 100-08,  12/29/2014 8948 
Chapter 3, Section 3.2.3.4 (Additional 
Documentation Request Required and 
Optional Elements) 
R548PI  10/17/2014  Deletion of Program Integrity Manual  11/18/2014 8904 
Exhibit 34 
R485PI  08/21/2013  Program Safeguard Contractor (PSC) and  01/29/2013 8079 
Zone Program Integrity Contractor (ZPIC) 
Provider Notification 
R446PI  12/28/2012  Program Safeguard Contractor (PSC) and  01/29/2013 8079 
Zone Program Integrity Contractor (ZPIC) 
Provider Notification  Rescinded and 
replaced by Transmittal 485 
R360PI  12/10/2010  Corrective Action Reporting  01/12/2011 7241 
R311PI  11/13/2009  Recovery Audit Contractors (RACs)  12/14/2009 6684 
R264PI  08/07/2008  Transition of Responsibility for Medical  08/15/2008 5849 
Review From Quality Improvement 
Organizations (QIOs) 
R224PI  10/16/2007  Revise the Fiscal Intermediary Shared  12/03/2007 5043 
System (FISS) to Expand Files to Include a 
National Provider Identifier (NPI) for Each 
Legacy Provider Identifier 
R220PI  08/24/2007  Various Medical Review Clarifications  09/03/2007 5550 
     
 
 
R213PI  06/29/2007  Various Benefit Integrity Revisions  07/30/2007 5630 
R209PI  06/12/2007  Revise the VIPS Medicare System (VMS)  07/02/2007 5044 
and Medicare Contractor System (MCS) to 
Expand Files to Include a National Provider 
Identifier (NPI) for Each Legacy Provider 
Identifier 
R201PI  05/11/2007  Revise the Fiscal Intermediary Shared  12/03/2007 5043 
System (FISS) to Expand Files to Include a 
National Provider Identifier (NPI) for Each 
Legacy Provider Identifier - Replaced by 
Transmittal 224 
R197PI  04/06/2007  Revise the VIPS Medicare System (VMS)  07/02/2007 5044 
and Medicare Contractor System (MCS) to 
Expand Files to Include a National Provider 
Identifier (NPI) for Each Legacy Provider 
Identifier - Replaced by Transmittal 209 
R176PI  11/24/2006  Various Benefit Integrity (BI) Clarifications 12/26/2006 5368 
R144PI  03/31/2006  Various Benefit Integrity (BI) Clarifications 05/01/2006 4247 
R143PI  03/17/2006  Demand Letters  04/17/2006 3954 
R141PI  02/24/2006  Modification to the UPIN Process  N/A  4191 
R118PI  08/12/2005  Various Benefit Integrity (BI) Clarifications 09/12/2005 3896 
R106PI  03/14/2005  Inclusion of Interventional Pain  04/04/2005 3721 
Management Specialists on Carrier 
Advisory Committee (CAC) Membership 
R096PI  01/14/2005  Consent Settlements  02/14/2005 3626 
R077PI  05/28/2004  Comprehensive Error Rate Testing (CERT)  06/28/2004 3229 
Requirements 
R071PI  04/09/2004  Rewrite of Program Integrity Manual  05/10/2004 3030 
(except Chapter 10) to Apply to PSCs 
R067PI  02/27/2004  Comprehensive Error Rate Testing (CERT)  03/12/2004 2976 
Requirements 
R047PI  07/25/2003  Definitions  08/08/2003 2517 
R044PI  07/25/2003  Replacing Contractor MR Web Sites with  10/01/2003 2592 
Medicare Coverage Database 
R032PI  10/22/2002  Harkin Grantee, Fraud Alerts  10/25/2002 2333 
R023PI  03/18/2002  Adds New Exhibits  05/02/2002 1981 
R017PIM  12/12/2001  Reorganizes chapter 3, sections 4, 5, and 6  04/01/2002 1891 
and Removes reference to outdated MCM 
and MIM overpayment collection 
instructions and lists the more current CFR 
citations instead. 
     
 
 
R016PIM  11/28/2001  Adds Various Program Memoranda for BI  11/28/2001 1732 
Requests for Information, Organizational 
Requirements, Unsolicited Voluntary 
Refund Checks, Anti-Kickback Statute 
Implications 
R014PIM  09/26/2001  Local Medical Review Policy (LMRP)  10/01/2001 1859 
Format and Submission/Requirements 
R009PIM  07/30/2001  LMRP Process  NA  1021 
R003PIM  11/22/2000  Complete Replacement of PIM Revision 1.  NA  1292 
R001PIM  06/2000  Initial Release of Manual  NA  931 
 
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