(General Information, Eligibility, and Entitlement Manual)

In disposing of this material, the contractor must:    Ensure the confidentiality of information regarding a particular beneficiary, provider, physician, or supplier by protective shredding, mutilation, or contractual provisions with the subcontractor regarding similar protective measures.    Provide for offsetting expenditures with salvage value received when contractual relationships have been established with a local contractor for the sale of non- claims materials for its salvage value.  In such cases, the contractor records the salvage value received, and offsets the initial expense of purchasing such materials by such value received.   30.80 - Standards for All Records Storage Facilities  (Rev. 38, Issued: 05 -26-06, Effective: 06- 26-06, Implementation: 06- 26-06)  A facility that is used to store Federal records, must meet the minimum structural, environmental, property and life safety standards as outlined in 36 CFR 1228.228- Facility Requirements http://www.access.gpo.gov/nara/cfr/waisidx_05/36cfr1228_05.html  by October 1, 2009.  You must submit a Facility Standards for Record Storage Facilities Inspection Checklist (see E xhibit 14) for all storage facilities used to house CMS records to the CMS Records Officer.   The facility must be constructed with non- combustible materials and building elements, including walls, columns and floors.  You may request a waiver of this requi rement from the National Archives and Records Administration through CMS for an existing records facility with combustible building elements to continue to operate until October 1, 2009.  Your request must provide documentation that the facility has a fire  suppression system specifically designed to mitigate this hazard and that the system meets the requirements in 36 CFR 1228.230--Fire Safety Requirements http://www.access.gpo. gov/nara/cfr/waisidx_05/36cfr1228_05.html .  Requests for waivers must be submitted to your CMS Regional Office contact who will forward to the CMS Records Officer for final approval by the National Archives and Records Administration.   30.90 - Exhibits  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06- 26-06)  Exhibit 1.  Preprinted Container Label  Exhibit 2.  Minimum Label Data Required for Unlabeled Boxes  Exhibit 3.  Records Transmittal and Receipt -  Standard Form 135 Exhibit 4.  Reference Request -  Federal Records Center -  Optional Form 11 Exhibit 5.  Certificate of Authenticity - Start  Exhibit 6.  Certificate of Authenticity - End Exhibit 7.  Correction Card  Exhibit 8.  Start of Retake or Addition Certificate  Exhibit 9.  Retake o r Addition Certification  Exhibit 10.  Resolution Test Chart  Exhibit 11.  Witness Disposal Certification (Sample)  Exhibit 12.  Roll Report  Exhibit 13  Report of Medicare Records  Exhibit 14  Inspection Checklist -- Standards for Record Storage Facilities  Exhibit 1 - Preprinted Container Label  (Rev.124, Issued: 05- 17-19, Effective: 06- 18-19, Implementation: 06- 18-19  ACCESSION NO.      CARTON NO.    of  AGENCY    MAJOR SUBDIVISION   DESCRIPTION OF RECORDS (BRIEF)    Instructions for Completing Label   Accession No.  - Control number you assign to each shipment of records.   Carton No. -  Show the box number and also the total number of boxes in the same shipment, e.g., 5 of 60.   Agency -  Enter CMS   Major Subdivision -  Enter the name of the MAC in this block.  Descri ption of Records -  Enter Part A A/B MAC (A) or (HHH) or Part B A/B MAC (B) or DME MAC -  Medicare bills and related claims records received, processed and paid (including dates), or Part A A/B MAC (A) or (HHH) - Medicare Fiscal Records, canceled checks and related records (including dates).   Also, for each box, show the inclusive  claims numbers , dates, etc., depending on arrangement of records.   Exhibit 2 - Minimum Label Data Required for Unlabeled Boxes  (Rev. 124, Issued: 05- 17-19, Effective: 06- 18-19, Implementation: 06 -18-19  For boxes not having a preprinted label (see Exhibit 1 above), enter the label as shown:   CARTON   _____   OF  ______  CARTONS   CMS   MAC NAME   CITY, STATE   MAC -  PAID MEDICARE BILLS   DATE TO DATE   (086- 12-8462A --093-14-2362T)   Instructions For Labeling Boxes   Use broad -point felt tip marker to facilitate shelf reference.   Minimum Label Data   Accession Number  - Control number assigned to each shipment of records.   Carton No. -  Show the box number and also total boxes in the shipment, e.g., 5 of 60.   Agency -  Show "CMS."   Office - Show the name of MAC with city and State address.  Description of Records -  For Medicare bills and related records, show:  "MAC name -  Paid Medicare Bills (inclusive dates)."  For fiscal records, can celed checks, and related records, show: " MAC -  Medicare Fiscal Records (inclusive dates)."   First and Last Entry in Box  - Show the inclusive claim number, terminal digit numbers, check numbers, or other designated key numbers.   Exhibit 3 - Records Trans mittal and Receipt - Standard Form 135  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06- 26-06)  Click on the link below then scroll down and click on Records Transmittal and Receipt Form -  SF135.   http://www.archives.gov/records_center_program/forms/sf_135_intro.html   Exhibit 4 - Reference Request - Federal Records Center - Optional Form 11  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementati on: 06- 26-06)  Click on the link below to access Optional Form 11  http://www.gsa.gov/forms   Exhibit 5 - Certificate of Authenticity - START  (Rev. 124, Issued: 05- 17-19, Effective: 06- 18-19, Implementation: 06- 18-19  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medi care Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.    CONTRACTOR NAME AND ADDRESS    CERTIFICATE OF AUTHENTICITY    START   THIS IS TO CERTIFY THAT THE MICROPHOTOGRAPHIC IMAGES APPEARING ON THIS ROLL OF MICROFILM:   STARTING WITH (e.g., control number, Medicare beneficiary identifier )  ARE ACCURATE REPRODUCTIONS OF THE RECORDS OF:   AND WERE MICROFILMED IN THE REGULAR COURSE OF BUSINE SS PURSUANT TO ESTABLISHED ROUTINE COMPANY POLICY FOR SYSTEMS UTILIZATION AND OR FOR THE MAINTENANCE AND PRESERVATION OF SUCH RECORDS THROUGH THE STORAGE OF SUCH MICROFILMS IN PROTECTED LOCATIONS.   IT IS FURTHER CERTIFIED THAT THE PHOTOGRAPHIC PROCESSES US ED FOR MICROFILMING OF THE ABOVE RECORDS WERE ACCOMPLISHED IN A MANNER AND ON MICROFILM THAT MEETS THE RECOMMENDED REQUIREMENTS OF THE NATIONAL BUREAU OF STANDARDS FOR PERMANENT MICROPHOTOGRAPHIC REPRODUCTIONS.   Date Microfilmed      Camera Operator   Locati on      Authorized Signature   Exhibit 6 - Certificate of Authenticity - END (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06- 26-06)   CONTRACTOR NAME AND ADDRESS    CERTIFICATE OF AUTHENTICITY    END   THIS IS TO CERTIFY THAT THE MICROPHOTOGRAPHIC IMAGES APPEARING ON THIS ROLL OF MICROFILM:   ENDING WITH   ARE ACCURATE REPRODUCTIONS OF THE RECORDS OF:   AND WERE MICROFILMED IN THE REGULAR COURSE OF BUSINESS PURSUANT TO ESTABLISHED ROUTINE COMPANY POLICY FOR SYSTEMS UTILIZATION AND OR FOR THE MAINTENANCE AND PRESERVATION OF SUCH RECORDS THROUGH THE STORAGE OF SUCH MICROFILMS IN PROTECTED LOCATIONS.   IT IS FURTHER CERTIFIED THAT THE PHOTOGRAPHIC PROCESSES USED FOR MICROFILMING OF THE ABOVE RECORDS WERE ACCOMPLISHED IN A MANNER AND ON MIC ROFILM THAT MEETS THE RECOMMENDED REQUIREMENTS OF THE NATIONAL BUREAU OF STANDARDS FOR PERMANENT MICROPHOTOGRAPHIC REPRODUCTIONS.   Date Microfilmed       Camera Operator   Location       Authorized Signature   Exhibit 7 - Correction Card  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06- 26-06)  CORRECTION CARD   CORRECTION  THIS DOCUMENT  HAS BEEN REPHOTOGRAPHED  TO ASSURE LEGIBILITY    Exhibit 8 - Start of Retake or Addition Certificate  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06 -26-06)  RETAKE OR ADDITION CARD START OF RETAKE OR ADDITION   The images appearing between this point and the "End of Retake or Addition" are true copies of records, which were missing or provide unsatisfactory on inspection of the origin al microfilm reel.   For a description of rephotographed material, see operator's "Retake or Addition Certificate" at the end of this section.    Exhibit 9 - Retake or Addition Certificate  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06- 26-06)  CONTRACTOR NAME AND ADDRESS   CERTIFICATE OF AUTHENTICITY   RETAKES OR ADDITIONS   THIS IS TO CERTIFY THAT THE MICROPHOTOGRAPHIC IMAGES APPEARING ON THIS ROLL OF MICROFILM:  ENDING WITH   ARE ACCURATE REPRODUCTIONS OF THE RECORDS OF:   AND WERE MICROFILMED IN THE REGULAR COURSE OF BUSINESS PURSUANT TO ESTABLISHED ROUTINE COMPANY POLICY FOR SYSTEMS UTILIZATION AND OR FOR THE MAINTENANCE AND PRESERVATION OF SUCH RECORDS THROUGH THE STORAGE OF SUCH MICROFILMS IN PROTECTED LOCATIONS.   IT IS FURTHER C ERTIFIED THAT THE PHOTOGRAPHIC PROCESSES USED FOR MICROFILMING OF THE ABOVE RECORDS WERE ACCOMPLISHED IN A MANNER AND ON MICROFILM THAT MEETS THE RECOMMENDED REQUIREMENTS OF THE NATIONAL BUREAU OF STANDARDS FOR PERMANENT MICROPHOTOGRAPHIC REPRODUCTIONS.   Date Microfilmed      Camera Operator   Location      Authorized Signature   Exhibit 10 - Resolution Test Chart  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06- 26-06)  The resolution test chart can also be viewed at the following link:   http://www.efg2.com/Lab/ImageProcessing/TestTargets/#Microcopy      Exhibit 11 - Witness Disposal Certification (Sample)  (Rev. 38, Issued: 05- 26-06, Effective: 06- 26-06, Implementation: 06 -26-06)  WITNESSED DISPOSAL CERTIFICATION  Disposal Date:   _____________________ Medicare Contractor:  ________________________________________ Address:    ________________________________________     ________________________________________ Disposal Location:  ________________________________________ _____________________________________________________________