100-08 Medicare Program Integrity Manual: Exhibits

Medicare Program Integrity Manual
Exhibits
Table of Contents
(Rev. 13890; Issued: 07-30-26)
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 48 - Guideline for Hospital Patient Status Reviews
Exhibit 49 – CERT Unified Post-Payment ADR Sample Letter
49.1 – OMHA e-Appeal Portal - How to Access the Portal
49.2 – How to Upload Documents via the OMHA e-Appeal Portal

Exhibit 50 – UPIC and I-MEDIC Fax Cover Sheet

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 Contractor’s (UPIC’s) 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 Attorney’s 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 beneficiary’s representative, or, in the case of a beneficiary dually entitled to
Medicare and Medicaid, a state as the beneficiary’s 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
ADDRESS:
CONTRACTOR 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 CMS’s 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 Medicare’s 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 CMS’s 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 provider’s or supplier’s 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 provider’s or supplier’s 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..."
For§1870: "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
de
Denied
Services 	#Sam
ple
Denied
Services 	#Univer
se
Down-coded
Services 	#Samp
le
Down-
coded
Services
#Univers
e
Potential
Overpayme
nt
[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. 13879; Issued: 07-23-26; Effective: 08-24-26; Implementation: 08-24-26)
A. Payment Suspension Initial Notice of Suspension Based on Fraud
[UPIC Information Header]
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:
[Provider Name]
Attn: [Point of Contact]
[Provider Street Address]
[Provider City, State Zip code]
From:
[UPIC Name - UPIC Region]
[Street Address]
[City, State, Zip Code]
The remainder of this page is intentionally blank.

Delivery Method: [INSERT]
[Date]
To:
[Provider Name]
Attn: [Point of Contact]
[Provider Street Address]
[Provider City, State Zip Code]
Reference Number: [INSERT HERE]
Provider Name: [INSERT HERE]
Provider NPI: [INSERT HERE]
Provider PTAN: [INSERT HERE]
Subject: Notice of Suspension of Medicare Payments
Dear [Point of Contact]:
[Use the following template to construct a Notice of Suspension (NOS) for a credible allegation
of fraud payment suspension. All NOS shall retain the formatting established in this template.
The body of the NOS shall be formatted to “justified” text alignment.]
The purpose of this letter is to notify you that the Centers for Medicare & Medicaid Services
(CMS), after consulting with the Department of Health and Human Services Office of Inspector
General, has decided to [SELECT FULL OR PARTIAL SUSPENSION LANGUAGE: fully
suspend Medicare payments to Click here to enter Provider/Supplier Name, (Click here to enter
abbreviated Provider/Supplier Name), pursuant to 42 C.F.R. § 405.371(a)(2) and 42 C.F.R. §
405.372(a)(4). OR partially suspend Medicare payments to Click here to enter abbreviated
Provider/Supplier Name at a rate of [X]%, pursuant to 42 C.F.R. § 405.371(a)(2) and 42 C.F.R. §
405.372(a)(4).] [SELECT NO PRIOR NOTICE OR PRIOR NOTICE LANGUAGE: The
suspension of Medicare payments took effect on [Month Day, Year]. Prior notice of this
suspension was not provided because giving prior notice would place additional Medicare funds
at risk and hinder CMS’ ability to recover any determined overpayment. See 42 C.F.R. §§
405.372(a)(3). OR The suspension of Medicare payments will take effect on [Month Day,
Year].]
The decision to suspend Medicare payments is based on credible allegations of fraud. CMS
regulations define credible allegations of fraud as allegations from any source including, but not
limited to, fraud hotline complaints verified by further evidence, claims data mining, and patterns
identified through audits, civil false claims cases, and law enforcement investigations. 42 C.F.R.
§ 405.370(a). Allegations are considered to be credible when they have indicia of reliability. Id.
This suspension will last until resolution of the ongoing investigation, as defined under 42 C.F.R.
§ 405.370(a).1
Allegation(s)
1 The Office of Inspector General, and the Department of Justice as appropriate, are consulted in all cases of suspected fraud as
required by 42 C.F.R. § 405.371(a)(2).

The suspension of Medicare payments to Click here to enter abbreviated Provider/Supplier Name
is based on, but not limited to, information that Click here to enter abbreviated Provider/Supplier
Name misrepresented services billed to the Medicare program. Specifically, the suspension of
Medicare payments is based on the following allegation(s) as well as the example claims below,
which we have included to provide evidence of the findings.
Allegation # (Rename this “Allegation 1” if there is more than one allegation.): [Refer to
Attachment A – Notice of Suspension Language Guide, Step 1 to identify and insert the
approved language reflective of the primary allegation. Insert the appropriate approved
language HERE.]
1. 	[See Attachment A, Step 2 to identify and insert the approved language
reflective of the subparagraph detail associated with the primary allegation.]
[Insert claim examples relevant to the subparagraph detail. Add rows if
necessary. If one claim box is used for multiple subparagraph details of an
allegation, the below statement should be inserted after the last subparagraph
detail, before the claim box: “The below claim control numbers (CCNs) are
examples of the allegations listed above.”]
Claim Control
Number (CCN)
Date(s) of Service
MM/DD/YYYY
2. 	[If necessary, add additional subparagraph detail associated with the primary
allegation. Use Attachment A, Step 2 to identify the approved language
reflective of the necessary subparagraph detail.]
[If additional subparagraph detail is added above, insert claim examples
relevant to the subparagraph detail. Add rows if necessary.]
CCN 	Date(s) of Service
MM/DD/YYYY
Allegation 2: (If another primary allegation needs to be added, repeat all steps listed
above. Continue repeating these steps to add allegations (e.g., Allegation 2, Allegation 3,
etc.) as necessary. If a secondary allegation is identified, use Attachment A, Step 3 to
insert the applicable approved language. If no additional allegations are needed after the
primary allegation, delete this section and move on.)
Investigation Process
The investigation into this matter is ongoing, and the claims listed above represent only a sample
of the problematic claims identified. The summary of allegations and the claims listed above
provide notice of the reasons for the payment suspension. As the investigation continues, you
may be asked to provide information. Click here to enter abbreviated Provider/Supplier Name
must be responsive to requests for documentation and information to prevent claim denials and
other administrative actions.
Right to Rebut

Pursuant to 42 C.F.R. § 405.372(b), you have the right to submit a written rebuttal statement,
including evidence supporting your rebuttal statement. Evidence provided in your rebuttal should
be specific to each allegation on which the suspension was based, including but not limited to the
claim examples provided.2 Merely providing general assertions or denials typically will be
insufficient to overcome the allegation(s). Your rebuttal statement should be received within 15
business days of receipt of this notice. Requests for additional time to submit a rebuttal statement
will be considered on a case-by-case basis.
If you choose to submit a rebuttal statement, your rebuttal statement should be sent to:
[UPIC Region] Unified Program Integrity Contractor
[Street Address]
[City, State, Zip Code]
Notice of Rebuttal Response
The suspension of Medicare payments will continue while your rebuttal statement is being
reviewed. See 42 C.F.R. § 405.375(a). You will be notified in writing of the response. The
response notice will include the findings regarding each allegation or condition upon which the
suspension is based and an explanation as to why the suspension of Medicare payments will
continue or be terminated. See 42 C.F.R. § 405.375(b)(2).
The response following your rebuttal is not an initial determination and is not appealable. See 42
C.F.R. § 405.375(c).
Disposition of Suspended Funds
The suspension of Medicare payments is based upon credible allegations of fraud, and, as such, a
determination will be made regarding an overpayment. A final decision regarding any
overpayment may be delayed until the resolution of the investigation. See 42 C.F.R. §
405.372(c)(2). An investigation is resolved when “legal action is terminated by settlement,
judgment, or dismissal, or when the case is closed or dropped because of insufficient evidence to
support the allegations of fraud.” 42 C.F.R. § 405.370. If an overpayment is determined, you will
receive a separate written notice from the Medicare Administrative Contractor that processes the
Medicare claims you submit, Click here to enter Name of MAC, advising you of the reasons for
the overpayment determination. 42 C.F.R. § 405.921(b).
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 overpayment, 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 balance be paid to another entity, the excess will be
released to Click here to enter abbreviated Provider/Supplier Name.
Processing of Claims During the Suspension
2 References in this letter to “rebuttal statement” include references to “evidence” submitted unless otherwise
indicated.

Claims will continue to be processed during the suspension period. 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.
[INSERT the following paragraph IF the provider is going to be placed on prepayment
review as part of the payment suspension.]
Also, CMS [SELECT ONE: is continuing OR has implemented] the process of reviewing
your Medicare claims and supporting documentation prior to payment. The purpose of the
prepayment process is to ensure that all payments made by the Medicare program are appropriate
and consistent with Medicare rules, regulations and policy. Notification is hereby given that you
are expected to comply with the prepayment process for claims for all dates and services.
Statutory Obligation to Return Overpayments
As a Medicare provider, you are responsible for monitoring compliance with Medicare
requirements. Upon discovering that payments were received in error, you are statutorily
required to return the overpayments within 60 days. See § 1128J(d)(2) of the Social Security Act
and 42 C.F.R. § 401.305.
If you have any questions regarding the status of the suspension, please direct your inquiry to
Click here to enter UPIC email address. Any request to remove the suspension must be submitted
through the written rebuttal process described above.
Sincerely,
[UPIC Company Name] – A CMS Unified Program Integrity Contractor
cc: Centers for Medicare & Medicaid Services
B. 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/Supplier’s 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).
The 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
C. 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/Supplier’s 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
D. 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/Supplier’s 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
E. Credible Allegation of Fraud (CAF) Payment Suspension Extension Notice
Date
To:
Attn: [Point of Contact]
[Provider Name]
[Provider Street Address]
[Provider City, State Zip code]
Reference Number:
Provider Name:
Provider Medicare ID Number (s):
Provider NPI:
Subject: Payment Suspension Extension Notice
Dear [Point of Contact]:
As previously advised in the Notice of Payment Suspension dated [date], the Centers for
Medicare & Medicaid Services (CMS) suspended payments to [Provider/Supplier Name
(“Shortened Name”)] based upon credible allegations of fraud under 42 C.F.R. § 405.371(a)(2).
CMS regulations authorize payment suspensions based upon credible allegations of fraud to
continue until resolution of the investigation including termination of any civil or criminal
proceedings. See 42 C.F.R. § 405.370 (defining “resolution of an investigation”) and §
405.372(d)(3)(ii).
Consistent with 42 C.F.R. § 405.371(b), CMS has (1) evaluated whether there is good cause to
not continue the payment suspension and (2) received a certification from the Office of Inspector
General (OIG) or other law enforcement agency that the matter continues to be under

investigation warranting continuation of the suspension. We are writing to inform you that the
payment suspension remains in place.
The maintenance of your payment suspension applies to claims in process. 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 [UPIC Email address].
Sincerely,
[UPIC PoC]
Program Integrity Manager
[Region] Unified Program Integrity Contractor
[Name of UPIC]
[Telephone]
F. Payment Suspension Termination Notice
USE THIS LETTER IF SENDING PAYMENT SUSPENSION TERMINATION NOTICE
TO THE PROVIDER’S/SUPPLIER’S ATTORNEY
Date
Name of Attorney
Address
City, State Zip
Re: 	Notice of Commencement of Process for Termination of Suspension of Medicare
Payments
Provider/Supplier Medicare ID Number(s):
Provider/Supplier NPI:
Record Identifier(s):
Dear {Medicare Provider/Supplier Attorney’s Name}:
The Centers for Medicare & Medicaid Services (CMS) has directed us to commence the process
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. As part of that process, the MAC will review our findings and will issue the overpayment
demand letter(s), along with information regarding the provider’s appeal rights. The MAC
typically will complete the process to terminate the suspension within approximately 60 days.
Once the payment suspension is terminated, any funds withheld as a result of the payment
suspension shall be applied first to reduce or eliminate any overpayments determined 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 the termination of the payment suspension should not be construed as a
positive determination regarding the provider’s 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
G. 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 Commencement of Process for Termination of Suspension of Medicare
Payments
Provider/Supplier Medicare ID Number(s):
Provider/Supplier NPI:
Record Identifier(s):
Dear {Medicare Provider/Supplier’s Name}:
The Centers for Medicare & Medicaid Services (CMS) has directed us to commence the process
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. As part of that
process, the MAC will review our findings and issue the overpayment demand letter(s), along
with information regarding your appeal rights. Typically, the MAC will complete the process to
terminate the suspension within approximately 60 days. 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 overpayments determined 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 the termination of a 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
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
Number Issue Description Interim
Response
Final
Response
Additional
Comments
Updated
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)
OIG Report Number
(e.g. A-01-09-00050)
(completed by MAC)
Overpayment
Recovery
(in dollars)
(completed by
MAC)
OPTIONAL
Overpayments
referred or
uncollectable
(in dollars)
(completed by MAC)
Reason for no
review of claims and
no recovery
(if applicable)
(completed by MAC)
Final Reporting
Date for this audit
(completed by
CMS)
Other Additional
Comments or
Actions Taken
(if applicable)

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
Columbia
Iowa

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:
Room 1405
JFK Federal Bldg.
Boston, MA 02203
(617) 565-2660
HHS, OS, OIG, OI
P.O. Box 8767
Boston, MA 02114
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont
NEW YORK
Room 3900 B
Federal Building
New York,
NY 10278
(212) 264-1691
HHS, OS, OIG, OI
P.O. Box 3209
Church St. Station
New York, NY 10008
New Jersey
New York
Puerto Rico
Virgin Islands
PHILADELPHIA
Room 4430
3535 Market Street
Philadelphia, PA
19104
(215) 596-6796
HHS, OS, OIG, OI
P.O. Box 8049
Philadelphia, PA
19101
Delaware
Pennsylvania
West Virginia
Maryland Except:
- Prince Georges County
- Montgomery County
Virginia Except:
- Fairfax County
- Arlington County
- City of Alexandria
- City of Falls Church
ATLANTA
Room 1404
101 Marietta Tower
Atlanta, GA 30323
(404) 331-2131/2556
HHS, OS, OIG, OI
P.O. Box 2288
Atlanta, GA 30301
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee
CHICAGO
23 rd Floor
105 West Adams St.
Chicago, IL 60603
(312) 353- 2740
HHS, OS, OIG, OI
23rd Floor
105 West Adams
Street
Chicago, IL 60603
Illinois
Indiana
Michigan
Minnesota
Ohio
Wisconsin
Missouri
Iowa
DALLAS
Room 4E1B
HHS, OS, OIG, OI
Room 4E1B
Arkansas
Louisiana

1100 commerce St.
Dallas, TX 75242
(214) 767-8406
1100 Commerce St.
Dallas, TX 75242
New Mexico
Oklahoma
Texas
DENVER
Room 327
1961 Stout Street
Federal Office Bldg.
Denver, CO 80294-
3546
(303) 844-5621
HHS, OS, OIG, OI
1961 Stout Street
Denver, CO 80294-
3546
Colorado
Kansas
Montana
Nebraska
North Dakota
South Dakota
Wyoming</>
Utah
SAN FRANCISCO
Room 174
50 U.N. Plaza
San Francisco, CA
94102
(415) 556-8880
HHS, OS, OIG, OI
P.O. Box 42516
San Francisco, CA
94142-2516
Arizona
California
Guam
Hawaii
Nevada
Samoa
SEATTLE SUB
OFFICE
Room 209, RX-81
2201 Sixth Avenue
Seattle, WA 98121
(206) 442-0547
HHS, OS, OIG, OI
P.O. Box 61220
Seattle, WA 98121
Alaska
Idaho
Oregon
Washington
WASHINGTON,
D.C. Field Office
Room 5193 Cohen
Bldg.
330 Independence Av.
SW
Washington, DC
20201
(202) 619-1900
HHS, OS, OIG, OI
Room 5193 Cohen
Bldg.
330 Independence Av
SW
Washington, DC
20201
District of Columbia
Maryland Counties:
- Prince Georges
- Montgomery Counties
- Virginia Counties
Virginia Cities
- Alexandria
- Falls Church
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 CMS’s 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
average response period for data requests made to CMS is 14 weeks.) 1
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 agency’s data request.
4. If, in the view of the requesting law enforcement agency, the Medicare contractor, or CMS,
the Medicare contractor’s “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
Attorney’s 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 individual’s 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 Justice’s]
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 Attorney’s 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
Attorney’s 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 Attorney’s 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
Attorney’s 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)
Contractor
Name
Identification
Number
Date of
DOJ
Request
Nature
of
Request
DOJ
Tracking
#
(if
provided)
Cost
to
Fill
SBR
Y or
N
Date of
SBR
Submission
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
and Assessment (Inc.
V.S.,
Response to Med.,
etc)
Includes all skilled observation and assessment
of the patient where the physician determines
that the patient's condition is such that a
reasonable 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
Care/Dressing
Includes irrigation of open, postsurgical
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
(Partial tissue loss
with signs of
infection
or full thickness
tissue loss, etc.)
Includes irrigation, application of medication
and/or dressing changes to decubitus. The
agency describes size (depth and width) and
appearance on an addendum when necessary.
Use this code 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
Training
Includes training of patients who have
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
(Including
postural drainage)
Includes breathing exercises, postural drainage,
chest percussion, conservation techniques, etc.
A11 	Adm. of Vitamin B-
12
Administration of vitamin B-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 IM/Subq Administration of any injection other than
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
Ileo conduit care
Teaching the patient or other person to care for
a colostomy, ileostomy or ileoconduit or
nephrostomy.
A16 	Teach Nasogastric
Feeding
Teaching the patient or other person to
administer nasogastric feedings. Includes
teaching care of equipment and preparation of
feedings.
A17 	Reinsertion
Nasogastric
Includes changing the tube by the nurse.
A18 	Teach Gastrostomy
Feeding
Teaching the patient or other person to care for
gastrostomy and administer feedings. Includes
teaching care of equipment and preparation of
feedings.
A19 	Teach Parenteral
Nutrition
Teaching the patient and/or family to 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
Injection
Teaching patient or other person to 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.
Enema
Includes nursing services associated with
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
Orders)
Includes any skilled nursing or teaching ordered
by the physician and not identified above. The
agency specifies what is being taught in Item 21
(Form CMS-485).
A28* Wound
Care/Dressing –
Closed
Incision/Suture Line
Skilled observation and care of surgical
incision/suture line including application of dry
sterile dressing. (See A4.)
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
Indwelling Catheter
Teaching patient or other person to care for
indwelling catheter.
A31 	Management and
Evaluation of Patient
Care Plan
The complexity of necessary unskilled services
require skilled management of a registered
nurse to ensure that these services achieve their
purpose, and to promote the beneficiary's
recovery and medical safety.
A32* Teaching and
Training (other)
(spec. under Orders)
Specify under physician orders.
* Code which requires a more extensive descriptive narrative for physician’s 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
Exercise
Exercises designed to restore function. Specific
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
Training
To evaluate and instruct safe transfers (bed, bath, 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
Upgrade Home
Program
To improve the patient's functional level by instruction
to the patient and responsible 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
Physical
Therapy
Includes breathing exercises, postural drainage, etc.,
for patients with acute or severe pulmonary
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
Therapy
Includes treatment for neuromuscular dysfunction 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
Training
Includes stump conditioning, (shrinking, shaping, etc.),
range of motion, muscle strengthening and gait training
with or without the prosthesis and appropriate assistive
devices.
B10 Fabrication
Temporary
Devices
Includes fabrication of temporary prostheses, braces,
splints, and slings.
B11 Muscle Re-
education
Includes therapy designed to restore function due to
illness, disease, or surgery affecting neuromuscular
function.
B12 Management
and Evaluation
of a Patient
Care Plan
The complexity of necessary unskilled services require
skilled management by a qualified physical therapist to
ensure that these services achieve their purpose, and to
promote the beneficiary's recovery and medical safety.
B13 Reserved
B14 Reserved

B15 Other (Spec.
Under Orders)
Includes all PT services not identified above. Specific
therapy services are identified under physician's orders
(Form CMS-485, Item 21).
* Code which requires a more extensive descriptive narrative for physician’s 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
Treatments
Procedures and treatment for patients with an
absence or impairment of voice caused by
neurologic impairment, structural
abnormality, or surgical procedures affecting
the muscles of voice production.
C3 	Speech Articulation
Disorders Treatments
Procedures and treatment for patients with
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
Treatments
Includes procedures and treatment for 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
Communications
Includes any procedures designed to establish
a non-oral or augmentive communication
system.

C9* Other (Spec. Under
Orders)
Speech therapy services not included above.
Specify service to be rendered under
physician's orders (Form CMS-485, Item 21).
* Code which requires a more extensive descriptive narrative for physician’s 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
Living/Daily Living
Skills (ADL Training)
Refers to the skills and performance of
physical cognitive and
psychological/emotional self care, work, 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
Training
Refers to enhancing skills necessary to
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
Coordination
Refers to the skills and the performance in
fine motor and dexterity activities.
D7 	Neurodevelop-mental
Treatment
Refers to enhancing the skills and the
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
(Fabrication and
Training)
Refers to the provision of special devices that
increase independent functions.
D11* Other 	Occupational therapy services not quantified
above.
* Code which requires a more extensive descriptive narrative for physician’s 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
and Emotional Factors
Skilled assessment of social and 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-
Range Planning and
Decision making
Assessment of patient's needs for long term
care including: Evaluation of home 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
Planning
The promotion of community centered
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
Orders)
Includes other medical social services 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 physician’s 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
Bath
Bathing or assisting the patient with bed 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 Ambulation Assisting the patient with ambulation as
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
Orders)
Includes other home health aide services 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 physician’s 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? (Physician’s 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 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 enforcement’s 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
DOJ’s legitimate law enforcement needs and the Medicare contractor’s 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 Attorney’s Office, DOJ’s 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 HCFA’s 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 cases—consistent with DOJ’s
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 MAC’s
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: 	Contractor’s 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’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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,theUniverse 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

Field Name 	Picture 	From 	Thru 	Initialization
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
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
DATA ELEMENT DETAIL
Claim (Header) Fields
Data Element: Contractor ID
Definition: 	Contractor’s 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.
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

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’.
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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: 	Beneficiary’s 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: 	Beneficiary’s 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: 	Contractor’s 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’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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: 	Contractor’s 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’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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: 	Contractor’s 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’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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: 	Beneficiary’s 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: 	Contractor’s 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’.
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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: 	Contractor’s 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’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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
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

Field Name 	Picture 	From 	Thru 	Initialization
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
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

Field Name 	Picture 	From 	Thru 	Initialization
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
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

Field Name 	Picture 	From 	Thru 	Initialization
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
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

Field Name 	Picture 	From 	Thru 	Initialization
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
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

Field Name 	Picture 	From 	Thru 	Initialization
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
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

Field Name 	Picture 	From 	Thru 	Initialization
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
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

Field Name 	Picture 	From 	Thru 	Initialization
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
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

Field Name 	Picture 	From 	Thru 	Initialization
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
Indicator Code 	X(1)
1992 	1992
Spaces
Patient Reason for Visit 2 Version
Indicator Code 	X(1)
1993 	1993
Spaces
Patient Reason for Visit 3 Version
Indicator Code 	X(1)
1994 	1994
Spaces
Present on Admission/External
Cause of Injury Indicator 	X(37)
1995 	2031
Spaces
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
Indicator Code 	X(1)
2116 	2116
Spaces
External Cause of Injury 2 Version
Indicator Code 	X(1)
2117 	2117
Spaces
External Cause of Injury 3 Version
Indicator Code 	X(1)
2118 	2118
Spaces
External Cause of Injury 4 Version
Indicator Code 	X(1)
2119 	2119
Spaces
External Cause of Injury 5 Version
Indicator Code 	X(1)
2120 	2120
Spaces
External Cause of Injury 6 Version
Indicator Code 	X(1)
2121 	2121
Spaces
External Cause of Injury 7 Version
Indicator Code 	X(1)
2122 	2122
Spaces
External Cause of Injury 8 Version
Indicator Code 	X(1)
2123 	2123
Spaces
External Cause of Injury 9 Version
Indicator Code 	X(1)
2124 	2124
Spaces
External Cause of Injury 10 Version
Indicator Code 	X(1)
2125 	2125
Spaces
External Cause of Injury 11 Version
Indicator Code 	X(1)
2126 	2126
Spaces
External Cause of Injury 12 Version
Indicator Code 	X(1)
2127 	2127
Spaces

Field Name 	Picture 	From 	Thru 	Initialization
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
Number 2
X(2) 	2174 	2175 	Spaces
Claim Demonstration Identification
Number 3
X(2) 	2176 	2177 	Spaces
Claim Demonstration Identification
Number 4
X(2) 	2178 	2179 	Spaces
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)
*From and Thru values relate to the 1st 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

Field Name 	Picture 	From 	Thru 	Initialization
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: 	Contractor’s 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’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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: 	Beneficiary’s 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 patient’s 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 patient’s 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
patient’s 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 Physician—the 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: 	Beneficiary’s 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 MAC’s 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 MAC’s 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)
DATA ELEMENT DETAIL
Data Element: 	Contractor ID
Definition: 	Contractor’s 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
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

Validation: 	Must be ‘A’ or ‘R’.
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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: 	Contractor’s 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’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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: 	Contractor’s 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’.
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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 provider’s 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: 	Provider’s 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: 	Provider’s 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 Address—The 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 Address—the 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 patient’s 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: 	Provider’s 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: 	Contractor’s 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’
Where the TYPE of BILL, 1st position = 3, Contractor Type should be ‘R’.
Where the TYPE of BILL, 1st/2nd 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: 	Contractor’s 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: 	Contractor’s 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: 	Beneficiary’s 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: 	Beneficiary’s 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: 	Contractor’s 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: 	Contractor’s 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: 	Contractor’s 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: 	Beneficiary’s 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: 	Contractor’s 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: 	Contractor’s 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

Field Name 	Picture 	From 	Thru 	Initialization
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
Claim Diagnosis Code 1Version
Indicator Code
X(1) 	273 	273 	Spaces
Claim Diagnosis Code 2 	X(7) 	274 	280 	Spaces
Claim Diagnosis Code 2Version
Indicator Code
X(1) 	281 	281 	Spaces
Claim Diagnosis Code 3 	X(7) 	282 	288 	Spaces
Claim Diagnosis Code 3Version
Indicator Code
X(1) 	289 	289 	Spaces
Claim Diagnosis Code 4 	X(7) 	290 	296 	Spaces
Claim Diagnosis Code 4Version
Indicator Code
X(1) 	297 	297 	Spaces
Claim Diagnosis Code 5 	X(7) 	298 	304 	Spaces
Claim Diagnosis Code 5Version
Indicator Code
X(1) 	305 	305 	Spaces
Claim Diagnosis Code 6 	X(7) 	306 	312 	Spaces
Claim Diagnosis Code 6Version
Indicator Code
X(1) 	313 	313 	Spaces
Claim Diagnosis Code 7 	X(7) 	314 	320 	Spaces
Claim Diagnosis Code 7Version
Indicator Code
X(1) 	321 	321 	Spaces
Claim Diagnosis Code 8 	X(7) 	322 	328 	Spaces
Claim Diagnosis Code 8Version
Indicator Code
X(1) 	329 	329 	Spaces
Claim Diagnosis Code 9 	X(7) 	330 	336 	Spaces
Claim Diagnosis Code 9Version
Indicator Code
X(1) 	337 	337 	Spaces
Claim Diagnosis Code 10 	X(7) 	338 	344 	Spaces
Claim Diagnosis Code 10Version
Indicator Code
X(1) 	345 	345 	Spaces
Claim Diagnosis Code 11 	X(7) 	346 	352 	Spaces
Claim Diagnosis Code 11Version
Indicator Code
X(1) 	353 	353 	Spaces
Claim Diagnosis Code 12 	X(7) 	354 	360 	Spaces
Claim Diagnosis Code 12Version
Indicator Code
X(1) 	361 	361 	Spaces
Claim Zip Code 	X(9) 	362 	370 	Spaces
Claim Pricing State 	X(2) 	371 	372 	Spaces

Field Name 	Picture 	From 	Thru 	Initialization
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
Number2
X(2) 	459 	460 	Spaces
Claim Demonstration Identification
Number3
X(2) 	461 	462 	Spaces
Claim Demonstration Identification
Number4
X(2) 	463 	464 	Spaces
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).
*From and Thru values relate to the 1st 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
Indicator Code
X(1) 	577 	577 	Spaces
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 Reason 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

Field Name 	Picture 	From 	Thru 	Initialization
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
Code
X(1) 	698 	698 	Spaces
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
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
Ambulance Point of Drop Off Zip
Code
X(9) 	758 	766 	Spaces
Line PWK 	X(60) 	767 	826 	Spaces
Prior Authorization Program 	X(4) 	827 	830 	Spaces
Unique Tracking Number (UTN) 	X(14) 	831 	844 	Spaces
Prior Authorization Affirmed
Indicator
X(1) 	845 	845 	Spaces
Filler 	X(6) 	846 	851 	Spaces
DATA ELEMENT DETAIL
Claim (Header) Fields
Data Element: Contractor ID
Definition: 	Contractor’s 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: 	Beneficiary’s 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 patient’s home, use the zip code from
the patient’s 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: 	Beneficiary’s 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 MAC’s 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 MAC’s 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
n Code
APP
Descriptio
APPA
M
APPM
DENA
M
DENM
R
Approved as a valid submission without manual
medical review.
Approved after automated medical review
Approved after manual medical review
routine
Approved after manual medical review complex. If
this code is selected, set the Manual Medial Review
Indicator to 'Y.
Denied after automated medical review
Denied 	for 	medical 	review 	reasons 	or 	for
insufficient documentation of medical necessity,
manual medical review routine
Denied for medical review reasons or for insufficient

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 MAC’s 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
Resolutio
n Code
Descriptio
DEO
RTP
REDA
M
REDM
R
REDM
C
REO
Review Indicator to 'Y.'
Denied for non-medical reasons, other than
denied as unprocessable.
Denied as unprocessable
(return/reject) Reduced after
medical review
Reduced for medical review reasons or for
insufficient documentation of medical necessity,
manual medical review routine
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.'
Reduced for non-medical review reasons.
Claim deleted from processing system—AC
maintains record of claim on system

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 MAC’s 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 patient’s home. If the 	service
was furnished in the patient’s home, use the zip code from the 	patient’s 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: 	Contractor’s 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: 	Contractor’s 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: 	Contractor’s 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: 	Provider’s 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 provider’s address.
Validation: 	N/A
Remarks: 	This is the address1 of the provider.
Requirement: Required
Data Element: Provider Address 2
Definition: 	2nd line of provider’s address.
Validation: 	N/A
Remarks: 	This is the address2 of the provider.
Requirement: Required if available
Data Element: Provider City
Definition: 	Provider’s city name.
Validation: 	N/A
Remarks: 	This is the city of the provider’s address.
Requirement: Required
Data Element: Provider State Code
Definition: 	Provider’s state code.

Validation: 	Must be a valid state code.
Remarks: 	This is the state of the provider’s address.
Requirement: Required
Data Element: Provider Zip Code
Definition: 	Provider’s zip code.
Validation: 	Must be a valid postal zip code.
Remarks: 	This is the zip code of the provider’s 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: 	Provider’s telephone number..
Validation: 	Must be a valid telephone number.
Remarks: 	This is the phone number.
Requirement: None
Data Element: Provider Phone Number Extension
Definition: 	Provider’s telephone number Extension.
Validation: 	Must be a valid telephone number.
Remarks: 	This is the phone number.
Requirement: None
Data Element: Provider Fax Number
Definition: 	Provider’s 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 Address—The 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 Address—the 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 patient’s medical 	records are
maintained
Requirement: 	Required
Data Element: Provider E-Mail Address
Definition: 	Provider’s 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: 	Contractor’s 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 OIG’s 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
Part A EAST
QIC Maximus, Inc.
Colorado, New Mexico, Texas, Oklahoma, Arkansas,
Louisiana, Mississippi, Alabama, Georgia, Florida,
Tennessee, South Carolina, North Carolina, Virginia, West
Virginia, Puerto Rico, Virgin Islands, Maine, Vermont, New
Hampshire, Massachusetts, Rhode Island, Connecticut, New
Jersey, New York, Delaware, Maryland, Pennsylvania,
Washington DC
Part A WEST
QIC
First Coast
Service
Options, Inc.
(FCSO)
Washington, Idaho, Montana, North Dakota, South Dakota,
Iowa, Missouri, Kansas, Nebraska, Wyoming, Utah,
Arizona, Nevada, California, Alaska, Hawaii, Oregon,
Kentucky, Ohio, Indiana, Illinois, Minnesota, Michigan,
Wisconsin, Guam, Northern Mariana Islands, American
Samoa
Administrative
QIC (AD QIC) Q2A 	N/A-Administrative QIC does not process reconsiderations.

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.
No. Position 	No.
of
Cols.
Item 	Description 	Comments
1. 	001 	1 	Record Code
9
1 = Add
2 = Add Develop/Return
3 = Assigned UPIN
4 = Registry Usage
5 = MPIER Update
6 = Update Develop/Return
7 = Notifications
2. 	002 	1 	Record Status
9
1 = Medical Doctor
2 = Other Doctor
3 = Non Physician/
Practitioner
4 = Group Practice
3. 	003-022 	20 	Last Name
X(20)
Physician/Health Care
Practitioner's Professional
Last Name. Valid Characters
A-Z and Blanks.
Left justify
Use Fields 3, 4, 5, and 6
for group name
4. 	023-036 	14 	First Name
X(14)
Physician/Practitioner's
Professional First Name.
Valid Characters A-Z and
Blank.
Left justify
5. 	037-042 	6 	Middle
Name/Initial
X(06)
Physician/Health Care
Practitioner's
Professional Middle
Name or Initial. Valid
Characters
A-Z and Blank
Left justify
6. 	043-045 	3 	X(03) 	Name Suffix.
Practitioner’s
Name Suffix
Example: JR, SR, III..
Valid Characters
A-Z and Blank.
Physician/Health Care
Left justify
7. 	046-070 	25 	Street
X(25)
Billing Street
Address
Left justify
NOTE: For "9" numeric fields, show zeroes if blank. For all "X" alpha numeric fields, if no info leave
field blank

Fld.
No. Position 	No.
of
Cols.
Item 	Description 	Comments
8. 	071-085 	15 	City
X(15)
City of Billing Address 	Left justify
9. 	086-087 	2 	State
X(02)
State of Billing Address 	Standard U.S. post office State
abbreviations.
10. 	088-096 	9 	ZIP Code
9(09)
ZIP Code of Billing Address 	Must report 9 position zip code
11. 	097-121 	25 	Street
X(25)
Business Street Address
The practice or physical
site address.
Left justify
12. 	122-136 	15 	City
X(15)
City of Business Address 	Left justify
13. 	137-138 	2 	State
X(02)
State of Business Address 	Standard U.S. post office State
abbreviations.
14. 	139-147 	9 	ZIP Code
9(09)
ZIP Code of Business
Address
Must report 9 position zip
code.
15. 	148-149 	2 	State
Licensed or
operating in
X (02)
State in which the
physician/Health Care
Practitioner is Licensed or
This Practice Setting.
Standard U.S. post office State
abbreviations.
16. 	150-161 	12 	Physician/
Health Care
Practitioner
State License/
Registration
Number X (12)
The State License Number or
Registration Number for this
Practice Setting.
Right justify and precede with
zeroes.
17. 	162-169 	8 	Date of Birth
9(08) (MMDDYYYY) **
18. 	169-173 	5 	Medical
School
Graduated
Code
X(05)
Medical School Code 	Refer to Exhibit 3.
19. 	174-177 	4 	Medical
School
Year
Graduated
9(04)
(YYYY) 	Year of Graduation

Fld.
No. Position 	No.
of
Cols.
Item 	Description 	Comments
20. 	178-185 	8 	Date of
Death
9(08)
(MMDDYYYY) **
21. 	186-188 	3 	Credentials
X (03) MD= Medical Doctor
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
9(02)
Specialty Code
Code Specified in Part 4 of
MCM §2207
23. 	191 	1 	Primary
Board
Certification
Indicator
X(01)
Y or N or U for Unknown

Fld.
No. Position 	No.
of
Cols.
Item 	Description 	Comments
24. 	192-193 	2 	Secondary
Specialty
Code
9(02)
Secondary Specialty Code
For This Practice Setting.
25. 	194 	1 	Secondary
Board
Certification
Indicator
X(01)
Y=Yes
N = No
U = Unknown
26. 	195 	1 	Type of
Sanction
Code
X(01)
Refer to Exhibit 4
27. 	196-199 	4 	Effective
Date of
Sanction
9(06)
(MMYY) Windowing
28. 	200-201 	2 	Number of
Sanctioned
Yrs
9(02)
Length of Sanction 01-99
29. 	202 	1 	Deactivate
Resident/Inte
rn Practice
Code
X(01)
D=Deactivate
R =Resident
I =Intern
P =Practice
O =OPT Out
30. 	203 	1 	Group
Practice
Indicator
9(01)
1=Group
4 =Solo
31. 	204 	1 	Physician/
Health Care
Practitioner/
Group
Practice
Participation
Indicator
X(01)
Y=Yes The participation
N=No decision is the latest
recorded.
32. 	205-218 	14 	Tax
Identification
Employer
Identification
no. X(14)
Any number
Number you assigned which
permits Identifying cross-
referencing Records For
One Individual
33. 	219-232 	14 	Carrier
Provider
Number
X(14)
(Use UPIN
for Record
Status 5 only)
The number you have provided
the Physician/Practitioner for
billing Medicare
Fld.
No. Position 	No.
of
Cols.
Item 	Description 	Comments

34. 	233-238 	6 	Registry's
Number the
Assigned
UPIN
Registry
X(06)
Leave blank 	This space reserved for UPIN
assignment
35. 	239-248 	10 	NHIC
Number
9(10)
Exception Turnaround
Numbering Assigned by Registry and
correction process
36. 	249-253 	5 	Incoming
Carrier
Number
9(05)
CMS Contractor Number;
Multi-state Contractor Use
The Distinct Number of
Each Jurisdiction.
37. 	254-268 	15 	Registry
Assigned
Error Codes
Or
Notification
Codes X(15)
Leave blank 	Used for Registry error
resolution/auto notification
38. 	269 	1 	Record
Validation
Field X(1)
Y=Yes
N=No Indicate that you have validated
the record with State Licensure
Board
39. 	270 	1 	Special
Processing
X(1)
Used to indicate special
processing record is being
submitted.
Acceptable Values:
Y = Indicates additional
settings being added.
1 = Indicates change to
Providers Name.
Record Code "1" with UPIN
Record Code “5” OLD LAST
NAME in Field
40. 	271-290 	20 	Special
Processing
Data X(20)
Used to cross check the change
to a Provider’s name or Provider
Number.
Name
Change Include the Providers LAST
name only as it appears on
the MPIER prior to the
change.
Record Code "5" Providers
NEW name in Fields 3, 4, 5, 6.
UPIN Field 34.
Provider
Number
Change
Include the Carrier assigned
Number as it appears on the
MPIER prior to the change.
Record Code "5" includes the
NEW provider Number in Field
33 UPIN in Field 34.
Individual
Social
Security
Number
Physician/Health Care
Practitioner Personal SSN Record returned To you will
contain the 10 Digit UPIN
41. 	292-301 	10 	10 X(10) 	Physician/Health Care
Practitioner/Group Record will contain
10-digit UPIN
42 	302-306 	5 	5 Digit
X(5) Filler 	Return record
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(01) 9 = Trailer Record
2. 	002-006 	5 	Incoming
Carrier
Number 9(05)
CMS Contractor Number;
Multistate Contractors Use
The Distinct Number Of
Each Jurisdiction
3. 	007-014 	6 	File
Creation9(06) (MMDDYYYY) Month,
Day, And Year Of File
Creation.
4. 	015-029 	15 	Number of
Records Sent
9(15)
Total Number Of Records
On The File. Do Not
Include The Trailer
Record.
Right justified and precede
with zeroes.
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 approver’s 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 RAC’s 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 Enforcement’s 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)
Revision History
Version 	Date 	Changed By 	Description of Change 	Signature Required
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

Table of Contents
Revision History.......................................................................................................................... 247
Table of Contents ........................................................................................................................ 249
1. Introduction ............................................................................................................................. 251
1.1 Purpose of the Supplemental Medical Review Contractor ............................................... 251
1.2 Purpose of the SMRC Joint Operating Agreement ........................................................... 251
1.3 Scope ................................................................................................................................. 251
1.4 Joint Operating Agreement Participants and Roles........................................................... 251
1.4.1 Supplemental Medical Review Contractor’s Role ..................................................... 252
1.4.2 Unified Program Integrity Contractor’s Role............................................................. 252
1.4.3 Centers for Medicare & Medicaid Services’ Role ..................................................... 253
1.5 Liability ............................................................................................................................. 253
1.6 Mutual Confidentiality ...................................................................................................... 253
1.7 Independent Contractors ................................................................................................... 254
1.8 Privacy ............................................................................................................................... 254
1.9 Funding.............................................................................................................................. 254
2. Communication ....................................................................................................................... 254
2.1 Contact Information .......................................................................................................... 254
2.2 Point of Contact Roles....................................................................................................... 254
2.3 Joint Operating Agreement Meetings ................................. Error! Bookmark not defined.
2.4 Workgroup Meetings........................................................... Error! Bookmark not defined.
2.5 Maintenance of the JOA.................................................................................................... 256
2.6 Dispute Resolution Process ............................................................................................... 256
2.7 Mailing Information .......................................................................................................... 257
3. Systems.................................................................................................................................... 257
3.1 Data Files........................................................................................................................... 257
3.2 Security.............................................................................................................................. 257
4. Processes ................................................................................................................................. 257
4.1 Misdirected Communications ........................................................................................... 257
4.2 Ad Hoc Reports ................................................................................................................. 258
4.3 Fraud Referral ................................................................................................................... 258
4.4 Process Improvement ........................................................................................................ 258
Appendix A. Master Contact List ............................................................................................... 259
Table A-1. Supplemental Medical Review Contractor ............. Error! Bookmark not defined.
Table A-2. Unified Program Integrity Contractor xxx............................................................ 259
Table A-3. Centers for Medicare & Medicaid Services .......................................................... 259

Appendix B. JOA Approval Signature Form .............................................................................. 259

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 Medicare’s 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 Party’s 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 Party’s CMS Contract. If there are any conflicts between the
terms of this Agreement and a Party’s CMS Contract, the terms of the Party’s CMS Contract shall
take precedence. The terms of this Agreement shall be interpreted so as to resolve any conflict
between it and a Party’s CMS Contract, and, if necessary, this Agreement shall be amended to
reconcile any unresolved conflict with a Party’s 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 Contractor’s 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 Contractor’s 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 party’s 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 party’s 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 party’s duties under this JOA, or as required by CMS
pursuant to each party’s 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 party’s 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
leader—Audit
UPIC Overpayment team
Leader—Recoupment
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 Contact’s 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 claims3. 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
Name
Date of
Birth
HIC
Number
Date of
Service
Rendering Provider /
Supplier
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.
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.
3 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 provider’s/supplier’s 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 patient’s medical record for each
encounter clearly identified for each requested beneficiary and the date of service. Providers/suppliers a re
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 claims 1 . 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, “Supplier’s 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 “Supplier’s 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 provider’s/supplier’s 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 Physician’s 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)
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 claims 8 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
Recovery Auditor
logo

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 RAC’s name) by
mm/dd/yyyy, the provider’s/supplier’s 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 RAC’s 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. 13890; Issued: 07-30-26; Effective: 08-28-26; Implementation: 08-28-26)
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
records4. 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 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.
4 Social 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 billing provider’s/supplier’s 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 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
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
• 	Via Fax: 804-261-8100
1. 	Use the coversheet as the only coversheet.
2. 	Do not add your own coversheet—this 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 cover sheet in your file transmission.
2. 	Information on esMD can be found at www.cms.gov/esMD.
3. 	For questions about esMD please contact: esMDBusinessOwners@cms.hhs.gov.
• 	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@empower.ai or via fax to 804-261-8100.
3. 	Must contain only images in TIFF or PDF format
• 	Via Email Attachment to CERTMail@empower.ai:
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 804-261-8100.
3. 	Must contain only attachments in TIFF or PDF format.

Questions
If you have any questions, please contact:
CERT Documentation Center
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
Email questions to: CERTProvider@empower.ai
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
Federal law
10
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
(Rev. 13000; Issued: 12-12-24; Effective: 12-10-24; Implementation: 12-10-24)
State 	POC 	Phon
e
POC E-mail Address
Alabama Beverly
Churchwell
(334)
242-
5318
Beverly.Churchwell@medicaid.alabama.go
v
Alaska 	Doug Jones
(907)
269-
0361
doug.jones@alaska.gov
American
Samoa
Matilda
Kruse
(684)
699-
4777
matilda.kruse@medicaid.as.gov
Arizona Vanessa
Templeman
(602)
877-
9066
Vanessa.Templeman@azahcccs.gov
Arkansas Heather
Callaway
(501)
687-
8349
Heather.callaway@arkansas.gov
California 	Bruce Lim
(916)
440-
7552
bruce.lim@dhcs.ca.gov
Colorado Bart
Armstrong
(303)
866-
4940
Bart.Armstrong@hcpf.state.co.us
Connecticut John
Jakubowski
(860)
424-
5855
John.Jakubowski@ct.gov
Delaware
Joe Riley
(acting)
(302)
255-
9647
Joe.Riley@delaware.gov
District of
Columbia
Kevin
O’Donnell
(202)
299-
5619
Kevin.Odonnell2@dc.gov
Florida Kelly
Bennett
(850)
412-
4600
Kelly.Bennet@ahca.myflorida.com
Georgia Johnny
Brooks
(404)
463-
7144
johnny.brooks@dch.ga.gov
Guam Jeffrey San
Nicolas
(671)
735-
7475
Jeffrey.Sannicolas@dphss.guam.gov

State 	POC 	Phon
e
POC E-mail Address
Hawaii Shelley
Siegman
(808)
692-
7962
SSiegman@dhs.hawaii.gov
Idaho 	Lori Stiles
(208)
334-
0653
stilesl@dhw.idaho.gov
Illinois 	Brian Dunn
(312)
833-
5835
Brian.J.Dunn@illinois.gov
Indiana 	Ben Ford
(317)
234-
7711
Benjamin.Ford@fssa.in.gov
Iowa Kimberly
Pierson
(515)
321-
8409
kpierso@dhs.state.ia.us
Kansas
Kansas
Department
of Health
and
Environmen
t
(785)
296-
1500 HCFProgramIntegrity@ks.gov
Kentucky Jennifer
Dudinskie
(502)
564-
5472
Jennifer.Dudinskie@ky.gov
Louisiana 	Angie Bihm
(225)
342-
9287
Angela.Bihm@LA.gov
Maine Valerie
Hooper
(207)
287-
4660
Valerie.Hooper@Maine.gov
Maryland Mary
Blackwell
(410)
767-
4332
Mary.Blackwell@Maryland.gov
Massachusett
s
Joan
Senatore
(617)
847-
3122
Joan.Senatore@state.ma.us
Michigan Michelle
Popowich
(517)
284-
6966
Popowichm@michigan.gov
Minnesota
Amanda
Novak
Kathryn
King-
Scribbins
(651)
431-
6378
(651)
431-
6956
Amanda.novak@state.mn.us
kathryn.king-scribbins@state.mn.us

State 	POC 	Phon
e
POC E-mail Address
Mississippi Richard
Cameron
(601)
576-
4134
Richard.Cameron@medicaid.ms.gov
Missouri 	VACANT
Montana 	Heather
Smith
(406)
444-
4120
HeatherSmith@mt.gov
Nebraska Anne
Harvey
(402)
471-
1718
anne.harvey@nebraska.gov
Nevada Cynthia
Leech
(775)
684-
7964 Cleech@dhcfp.nv.gov
New
Hampshire
Karen
Carleton,
RN
Francesca
Hennessy
(603)
271-
8029
(603)
271-
5134
Karen.Carleton@dhhs.nh.gov
Francesca.Hennessy@dhhs.nh.gov
New Jersey
Joshua
Lichtblau
Don
Catinello
Nina
Galletto
(609)
292-
4368
(609)
789-
5014
(609)
789-
5031
Joshua.Lichtblau@osc.nj.gov
Don.Catinello@osc.nj.gov
Nina.Galletto@osc.nj.gov
New Mexico
Lisa V.
Medina-
Lujan
(505)
827-
7310
Lisa.Medina-Lujan@hsd.nm.us
New York
Frank T.
Walsh, JR
(514)
473-
8782
Frank.Walsh@omig.ny.gov
North
Carolina
John E.
Thompson
(919)
527-
7701
John.E.Thompson@dhhs.nc.gov
North Dakota
Denise
Martino
(701)
328-
4024
Dmmartino@nd.gov
Northern
Mariana
Islands
Annie Rose
Z. Reyes
(670)
664-
4883
annierosezandueta@cnmimedicaid.com

State 	POC 	Phon
e
POC E-mail Address
Ohio Jeffrey
Corzine
(614)
387-
8369
Jeffrey.corzine@medicaid.ohio.gov
Oklahoma 	Julie Dowell
(405)
522-
7421
Julie.Dowell@okhca.org
Oregon
Fritz Jenkins
Tamara
McNatt
(503)
358-
5246
Fritz.Jenkins@odhsoha.oregon.gov
Tamara.McNatt@dhsoha.state.or.us
Pennsylvania
Karen
Fickes
(717)
705-
6858
kfickes@pa.gov
Puerto Rico
Maria D.
Garcia-
Ducos
(787)
765-
2929
Ext.
6756
maria.garcia.ducos@salud.pr.gov
Rhode Island
Christopher
Smith
(401)
463-
0163
Christopher.smith@ohhs.ri.gov
South
Carolina
Michael
Targia (803)
898-
2608
Michael.Targia@scdhhs.gov
South Dakota 	Stacy Bruels
(605)
773-
3745
Stacy.Bruels@state.sd.gov
Tennessee 	Floyd Price
(615)
507-
6686
Floyd.N.Price@tn.gov
Texas Steve
Johnson
(512)
415-
7980
Steve.Johnson@hhs.texas.gov
Utah Gene
Cottrell
(801)
599-
4372
GCottrell@utah.gov
Vermont Nadeth
Fitzgerald
(802)
760-
9432
Nadeth.Fitzgerald@vermont.gov

State 	POC 	Phon
e
POC E-mail Address
Virgin Islands Kevin
Dennin
(340)
774-
0930
Ext.
4478
Kevin.Dennin@dhs.vi.gov
Virginia Tracy
Sargent
(804)
371-
2648
Tracy.Westerman@dmas.virginia.gov
Washington Michael
Brown
(360)
725-
0913
Michael.brown@hcs.wa.gov
West Virginia Andrew
Pack
(304)
352-
4253
Andrew.C.Pack@wv.gov
Wisconsin
Anthony
Baize
(608)
266-
2521
Anthony.Baize@dhs.winsconsin.gov
Wyoming
Andrew
Chapin
Susan Malm
Portia
Peterson
(307)
777-
2504
(307)
777-
5609
(307)
777-
8985
Andrew.Chapin@wyo.gov
Susan.Malm@wyo.gov
Portia.Pterson1@wyo.gov

Step 3- Did the provider render a medically necessary
service
Severity of Signs and Symptoms, and
Step 2- Did the Patient Need Hospital Care?
Exhibit 48 - Guideline for Hospital Patient Status Reviews
(Rev. 13409; Issued: 09-12-25; Effective: 10-13-25; Implementation: 10-13-25)
Note- If any of the following unforeseen
circumstances
resulted in a shorter stay, the stay is payable
under Part A:
• 	Death,
• 	Transfer,
• 	Departures Against Medical
Advice (AMA),
• 	Clinical Improvement,
• 	Election of Hospice
No
Claim is NOT Payable
under Part A
Claim is NOT
Payable under
Part A

* Reviewers shall consider complex medical factors that support a reasonable expectation of the needed
duration of the stay relative to the 2-midnight benchmark. Both the decision to keep the beneficiary at the
hospital and the expectation of needed duration of the stay are based on such complex medical factors as
beneficiary medical history and comorbidities, the severity of signs and symptoms, current medical needs,
and the risk (probability) of an adverse event occurring during the time period for which hospitalization is
considered.
Legal Disclaimer: This educational product was prepared as a service to the public and is not intended to
grant rights or impose obligations. This educational product may contain references or links to statutes,
regulations, or other policy materials. The information provided is only intended to be a general summary. It
is not intended to take the place of either the written law or regulations. We encourage readers to review the
specific statutes, regulations, and other interpretive materials for a full and accurate statement of their
contents.
Exhibit 49 – Exhibit 49 – OMHA e-Appeal Portal
(Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26)
The OMHA e-Appeal Portal is a secure, web-based system that allows parties to
electronically manage Medicare appeals before OMHA, including submitting case
information and documents online instead of relying on paper and mail. The following
exhibits are designed to help users effectively utilize this system: one provides step-by-
step instructions for creating and accessing a portal account, and the other explains how
to upload appeal documents within the portal so that information is properly associated
with the correct case.
Exhibit 49.1 – OMHA e-Appeal Portal - How to Access the Portal
(Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26)
The OMHA e-Appeal Portal is available at <hhs-ecape-portal.entellitrak.com>.
Portal Account Creation:
To create a new portal account, navigate to the website at <hhs-ecape-
portal.entellitrak.com>. Then select the green button labeled “Sign in with ID.me.” You
will be redirected to ID.me and prompted to sign in or create an ID.me account.
The portal utilizes ID.me to provide identity verification for new accounts and multi-
factor authentication for secure sign-in to existing accounts. Creating an ID.me account
requires a picture ID (such as a driver's license or passport) and an email address or
phone number for verification. It usually takes about 15-20 minutes. In some situations,
a live video call may be required to verify a new user’s identity.
Once you finish signing in to or creating an account with ID.me, you will be redirected
back to the portal’s user registration page and prompted to enter some profile
information. Once you’ve entered the required information, click “Register” and you
will be directed to your portal account’s home page.
Portal Account Sign-in:

To sign-in to an existing portal account, navigate to the website at <hhs-ecape-
portal.entellitrak.com>. Then select the green button labeled “Sign in with ID.me.” You
will be redirected to ID.me and prompted to sign in with multi-factor authentication to
your ID.me account. Once you have signed into ID.me, you will be transferred to your
portal account’s home page.
Exhibit 49.2 – How to Upload Documents via the OMHA e-Appeal
Portal
(Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26)
To upload documents to an existing Level 3 appeal, sign-in to the portal. From the main
page, select the “Upload Additional Documents to an Appeal tab” on the left side of the
page.
Enter the OMHA appeal number and then select the file(s) you wish to upload to the
appeal by clicking the “Add Another File” button.

Once the OMHA appeal number is entered and the desired files are added, click
“Submit.”
A confirmation pop-up question will appear, asking “Are you sure you would like to
submit the Attachment?” Click “OK.”
After you select “OK,” a screen will appear to confirm the files were uploaded. The
appeal number and the file name(s) uploaded will be listed. You will also receive an e-
mail confirmation.
Note: Use caution when entering the appeal number to avoid adding files to the wrong
appeal. Avoid using any spaces before or after the appeal number. The Administrative
Law Judge and team assigned to the appeal will receive an alert that a document was
uploaded to the appeal. You may upload multiple documents, but each file is restricted
to 50MB. If the file is larger than 50MB, it will need to be broken down into smaller
files and then uploaded. The following file types can be uploaded: PDF, RTF, Word,
Excel, PowerPoint, BMP, JPEG, PICT, TIFF, CSV, and XML.

Exhibit 50 – UPIC and I-MEDIC Fax Cover Sheet
(Rev. 13595; Issued: 01-26-26; Effective: 02-26-26; Implementation: 02-26-26)

Transmittals Issued for this Chapter

Rev # 	Issue Date 	Subject 	Impl Date CR#
R13890PI 07/30/2026 	Revisions to Chapter 12 (The
Comprehensive Error Rate Testing (CERT)
Program) and Exhibit 46 in the Exhibits
Chapter of Publication (Pub.) 100-08
(Medicare Program Integrity Manual)
08/28/2026 14539
R13821PI 06/09/2026 	Updates of Chapters 3, 4, and Exhibits in
Publication (Pub.) 100-08, Including
Updates to the Provider Notification
Process and Vetting with the CMS Process
02/26/2026 14362
R13595PI 01/26/2026 	Updates of Chapters 3, 4, and Exhibits in
Publication (Pub.) 100-08, Including
Updates to the Provider Notification
Process and Vetting with the CMS Process-
Rescinded and replaced by Transmittal
13821
02/26/2026 14362
R13409PI 09/12/2025 	Update to Medical Review Instructions for
Inpatient Hospital Claims in Chapter 6 of
Publication (Pub.) 100-08, Program
Integrity Manual (PIM)
10/13/2025 14207
R13110PI 04/11/2025 	Updates of Chapter 8 and Exhibit 16 in
Publication (Pub.) 100-08, Including
Unified Program Integrity Contractor
(UPIC) Payment Suspension Protocols
05/12/2025 13930
R13000PI 12/12/2024 	Updates of Chapter 4 and Exhibits in
Publication (Pub.) 100-08, Including the
Unified Program Integrity Contractor
(UPIC) and Medical Review Accuracy
Contractor (MRAC) Coordination Process
12/10/2024 13850
R12954PI 11/08/2024 	Updates of Chapter 4 and Exhibits in
Publication (Pub.) 100-08, Including the
Unified Program Integrity Contractor
(UPIC) and Medical Review Accuracy
Contractor (MRAC) Coordination Process-
- Rescinded and replaced by Transmittal
13000
12/10/2024 13850
R12642PI 05/16/2024 	Revisions to Chapter 12 (The
Comprehensive Error Rate Testing (CERT)
Program) of Publication (Pub.) 100-08
(Medicare Program Integrity Manual) and
Deletions to Exhibit 34 in the Exhibits
Chapter of Pub. 100-08
06/17/2024 13602

R12515PI 02/22/2024 	Updates of Chapter 4, Chapter 8, and
Exhibits in Publication (Pub.) 100-08,
Including Prioritization and Payment
Suspension Language Guidance
02/22/2024 13508
R11218PI 01/27/2020 	Updates to Chapter 4 in Publication (Pub.)
100-08, Including Removal of Requests for
Anticipated Payment (RAP) Suppressions
and Updates to Exhibit 16 - Model
Payment Suspension Letters in Pub. 100-08
02/28/2022 12595
R10910PI 08/10/2021 	Updates to Exhibit 16 in Exhibits Chapter
of Publication (Pub.) 100-08
09/13/2021 12385
R10383PI. 10/09/2020 	Updates to Chapters 4, 5, 8, 15, and Exhibits
of Publication (Pub.) 100-08
11/10/2020 11199
R10228PI 07/27/2020 	Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8,
10, 11, and Exhibits of Publication (Pub.)
100-08
08/27/2020 11884
R943PI 	02/21/2020 	Updates to Chapter 4 and Exhibit 8 in
Publication (Pub.) 100-08
03/24/2020 11629
R902PI 	09/27/2019 	Updates to Chapters 3, 4, 8, 15, and
Exhibits of Publication (Pub.) 100-08
10/28/2019 11425
R884PI 	05/31/2019 	Update to Exhibit 46.2, 46.3, 46.4, and 46.5
in Publication (Pub.) 100-08
08/30/2019 11242
R867PI 	02/22/2019 	Update to Exhibit 16 - Model Payment
Suspension Letters in Publication (Pub.)
100-08
03/25/2019 11088
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
Suspension Letters in Publication (Pub.)
100-08
10/01/2018 10849
R826PI 	09/21/2018 	Update to Chapter 4, Section 4.18.1.4 and
Exhibit 16 in Publication (Pub.) 100-08
10/22/2018 10853
R823PI 	08/31/2018 	Update to Exhibit 16 - Model Payment
Suspension Letters in Publication (Pub.)
100-08- Rescinded and replaced by
Transmittal 831
10/01/2018 10849
R780PI 	03/16/2018 	Update to Exhibit 16 - Model Payment
Suspension Letters in Pub. 100-08
05/16/2018 10498

R726PI 	06/16/2017 	Comprehensive Error Rate Testing (CERT)
File Layout for Social Security Number
Removal Initiative (SSNRI)
10/02/2017 9835
R714PI 	05/12/2017 	Comprehensive Error Rate Testing (CERT)
File Layout for Social Security Number
Removal Initiative (SSNRI) – Rescinded
and replaced by Transmittal 726
10/02/2017 9835
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)
program Treatment of Claims in the Prior
Authorization Model
07/05/2016 9238
R637PI 	02/05/2016 	Comprehensive Error Rate Testing (CERT)
program Treatment of Claims in the Prior
Authorization Model – Rescinded and
replaced by Transmittal 660
07/05/2016 9238
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
(Pub. 100-08) Exhibit 36 - Overview of the
Comprehensive Error Rate Testing (CERT)
Process
12/29/2014 8859
R557PI 	11/26/2014 	Update to CMS Publication 100-08,
Chapter 3, Section 3.2.3.4 (Additional
Documentation Request Required and
Optional Elements)
12/29/2014 8948
R548PI 	10/17/2014 	Deletion of Program Integrity Manual
Exhibit 34
11/18/2014 8904
R485PI 	08/21/2013 	Program Safeguard Contractor (PSC) and
Zone Program Integrity Contractor (ZPIC)
Provider Notification
01/29/2013 8079
R446PI 	12/28/2012 	Program Safeguard Contractor (PSC) and
Zone Program Integrity Contractor (ZPIC)
Provider Notification – Rescinded and
replaced by Transmittal 485
01/29/2013 8079
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
Review From Quality Improvement
Organizations (QIOs)
08/15/2008 5849

R224PI 	10/16/2007 	Revise the Fiscal Intermediary Shared
System (FISS) to Expand Files to Include a
National Provider Identifier (NPI) for Each
Legacy Provider Identifier
12/03/2007 5043
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)
and Medicare Contractor System (MCS) to
Expand Files to Include a National
Provider Identifier (NPI) for Each Legacy
Provider Identifier
07/02/2007 5044
R201PI 	05/11/2007 	Revise the Fiscal Intermediary Shared
System (FISS) to Expand Files to Include a
National Provider Identifier (NPI) for Each
Legacy Provider Identifier - Replaced by
Transmittal 224
12/03/2007 5043
R197PI 	04/06/2007 	Revise the VIPS Medicare System (VMS)
and Medicare Contractor System (MCS) to
Expand Files to Include a National
Provider Identifier (NPI) for Each Legacy
Provider Identifier - Replaced by
Transmittal 209
07/02/2007 5044
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
Management Specialists on Carrier
Advisory Committee (CAC) Membership
04/04/2005 3721
R096PI 	01/14/2005 	Consent Settlements 	02/14/2005 3626
R077PI 	05/28/2004 	Comprehensive Error Rate Testing (CERT)
Requirements
06/28/2004 3229
R071PI 	04/09/2004 	Rewrite of Program Integrity Manual
(except Chapter 10) to Apply to PSCs
05/10/2004 3030
R067PI 	02/27/2004 	Comprehensive Error Rate Testing (CERT)
Requirements
03/12/2004 2976
R047PI 	07/25/2003 	Definitions 	08/08/2003 2517

R044PI 	07/25/2003 	Replacing Contractor MR Web Sites with
Medicare Coverage Database
10/01/2003 2592
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
and Removes reference to outdated MCM
and MIM overpayment collection
instructions and lists the more current CFR
citations instead.
04/01/2002 1891
R016PIM 	11/28/2001 	Adds Various Program Memoranda for BI
Requests for Information, Organizational
Requirements, Unsolicited Voluntary
Refund Checks, Anti-Kickback Statute
Implications
11/28/2001 1732
R014PIM 	09/26/2001 	Local Medical Review Policy (LMRP)
Format and Submission/Requirements
10/01/2001 1859
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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