CMS Pub. 100-01, ch. 7, § 30.30.1.5

Overutilization Has Been Identified

(Rev. 38, Issued: 05-26-06, Effective: 06-26-06, Implementation: 06-26-06)

When potential fraud or overutilization has been identified, retain the recordkeeping copy onsite.

If the recordkeeping copy has already been transferred to offsite storage, retrieve and retain

onsite until the investigation and subsequent legal action, if any, has been completed (including

the exhaustion of all appeals), then destroy 3 months thereafter.

If at the close of this period, the disposition instructions shown in §30.30.1.1 through 30.30.2

remains applicable, retain, transfer, and destroy in accordance with the disposition instructions.

If the disposition instructions in §30.30.1.1 through 30.30.2 are no longer applicable, then

destroy after the 3 month period following completion of the investigation or subsequent legal

action, if any.

If any records are provided to a prosecutorial agency as evidentiary matter, consider such records

as disposed of. If any such record is returned by the prosecutorial agency, retain for 3 months,

then destroy in accordance with the foregoing disposition instructions unless otherwise directed

by the prosecutorial agency.

30.30.2 - Description of Records

(Rev. 124, Issued: 05-17-19, Effective: 06-18-19, Implementation: 06-18-19 The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's

Medicare identification number. For purposes of this manual, Medicare beneficiary identifier

references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary

Identifier (MBI) during the new Medicare card transition period and after for certain business

areas that will continue to use the HICN as part of their processes.

1. Medicare Claims Records:

A. A/B MAC (A) or (HHH) Billing Records (FROZEN - DO NOT DESTROY)

These files consist of Inpatient and/or Outpatient Billing forms, and other documents

used to bill for services processed by A/B MACs (A) or (HHH) i.e., inpatient hospital,

outpatient hospital, SNF, hospice, home health, etc.

DISPOSITION: Once the freeze is lifted, cutoff at the close of the CY in which paid.

Destroy 6 years and 3 months after cutoff.

B. A/B MAC (B) or DME MAC Billing Records (FROZEN - DO NOT DESTROY)

These files consist of Requests for Payment and similar forms. Also included are

itemized bills, correspondence (including correspondence with district offices), and

comparable documents used to support payment to beneficiaries, physicians, and other

suppliers of services under the Supplemental Medical Insurance (SMI) Program.

DISPOSITION: Once the freeze is lifted, cutoff at the close of the CY in which paid.

Destroy 6 years and 3 months after cutoff.

2. Medicare Benefit Check Records (FROZEN - DO NOT DESTROY)

These files consist of paid checks that contractors receive from banks covering amounts paid to

providers of service, beneficiaries, physicians, and other suppliers of service under the Hospital

Insurance and Supplementary Medical Insurance (SMI) programs. Also included are check

vouchers and cancelled or voided checks resulting from nonreceipt, loss, theft, or non-delivery.

Disposition: The contractor cuts off the file at the close of the calendar year in which issued,

holds the file for 1 additional year, and then transfers it to inactive storage. Once the freeze is

lifted, the file is destroyed after a total of 6 years and 3 months retention.

When fraud or overutilization of services is involved, the contractor retains the hard copy claim

until 3 months after the resolution of the investigation OR reverts to normal disposition,

whichever is longer.

3. Medicare Summary Notices (MSNs) (FROZEN - DO NOT DESTROY)

These files consist of MSNs used to advise beneficiaries about remaining Part A benefits, Part A

and Part B deductible status, and about applying for complementary health benefits.

Disposition: The contractor cuts off the file at the close of the calendar year in which benefit

was paid or denied, as applicable, holds for 1 additional year and then transfers to inactive

storage. Once the freeze is lifted, remove them from inactive storage for destruction after a total

of 6 years and 3 months retention from cut off.

4. Reconsideration and Hearing Case Files - Hospital Insurance Program (FROZEN - DO

NOT DESTROY)

Reconsideration records accumulate when a beneficiary or their representative is dissatisfied

with the A/B MAC (A) or (HHH)'s determination denying payment, or with the amount of

benefits payable on the beneficiary's behalf under the Hospital Insurance Program and files either

an expressed or implied request for reconsideration. Hearing case records accumulate when a

beneficiary or their representative is dissatisfied with the reconsideration determination and

requests a hearing; and if still dissatisfied after the hearing, files for a subsequent court review.

Included are Forms CMS-2649, Request for Hearing; CMS-561, Request for Reconsideration; or

their equivalents. Also included are evidence furnished by beneficiaries or their representatives,

correspondence, CMS determinations, Administrative Law Judge decisions, original bills,

Appeals Council decisions and similar material.

Disposition: Once the freeze is lifted, the contractor disposes of these records in accordance with

instructions for Medicare claims records.

5. Review and Fair Hearing Case Files - Supplementary Medical Insurance Program

(FROZEN - DO NOT DESTROY)

This category includes files accumulated when a beneficiary, physician, provider, or other

supplier of service is dissatisfied with the MAC’s determination denying a request for payment,

or with the amount of the payment, or with the reasonable promptness of action on a request for

payment. Included are copies of claimant's requests for review, relevant written statements or

evidence, notices of adverse formal review decisions, requests for hearings to protest the adverse

decisions, hearings proceedings, hearing officers' final decisions, and other comparable papers.

Disposition: The contractor places these records in an inactive file upon final action on the case.

It cuts off the inactive file at the close of the calendar year in which the final action was taken,

and holds it for 2 additional years, then transfers it to off-site storage. Once the freeze is lifted,

these records can be destroyed when 5 years old.

6. A/B MACs (A) and (HHH) and A/B MAC (B) or DME MAC Administrative Budget

Estimate and Cost Report Form (FROZEN - DO NOT DESTROY)

These files consist of all uses of the Administrative Cost and Budget Report, CMS-1523 for A/B

MAC (B) or DME MAC and CMS-1524 for A/B MACs (A) or (HHH). This form is a multi-use

document and issued for budget and cost reporting activities.

Specific uses are:

a. Budget request, supplemental budget request, notice of budget approval, interim

expenditure report.

Disposition: Once the freeze is lifted, destroy after a total retention of 3 years after HHS

audit and final settlement.

b. Supplemental Budget Request

Disposition: Once the freeze is lifted, destroy after a total retention of 3 years after HHS

audit and final settlement.

c. Notice of Budget Approval. The MAC’s certified funding authority for the fiscal year.

Include all supporting schedules, correspondence and justification.

Disposition: Once the freeze is lifted, destroy after a total retention of 3 years after HHS

audit and final settlement.

d. Interim Expenditure Report. Cumulative fiscal year to date expenditures incurred by

the MAC. Include all supporting schedules, correspondence and justifications.

Disposition: Once the freeze is lifted, destroy after a total retention of 3 years after HHS

audit and final settlement.

e. Final Administrative Cost Proposal. The final statement of expenditures for the fiscal

year. This form is used as the basis for final settlement of allowable costs. Include all

supporting schedules, correspondence, HHS or GAO audit reports on administrative cost

and benefits payments.

Disposition: Once the freeze is lifted, destroy after a total retention of 6 years and 3

months after HHS audit and final settlement.

7. MAC Letter of Credit Files (FROZEN - DO NOT DESTROY)

These records are authorizations to a Federal Reserve Bank to disburse funds to designated

MACs’ banks on behalf of CMS upon presentation of request for funds for collection through the

Federal Reserve System. Included are Standard Form 1193, Letter of Credit or its equivalent,

and amending letters.

Disposition: Once the freeze is lifted, destroy after a total retention of 6 years and 3 months after

the year in which the letters of credit are cancelled.

8. A/B MAC (A) or (HHH) Payment Vouchers and Transmittal Files (FROZEN - DO NOT

DESTROY)

These consist of Form TFS-218, Request for Funds, and similar documents prepared by the A/B

MAC (A) or (HHH)’s servicing bank to obtain Federal funds for benefits paid in administering

medical insurance programs. Also included is Form CMS-1521, Payment Voucher on Letter of

Credit, a transmittal that forwards information on request for funds to CMS and shows the

purpose for which funds were drawn, i.e., hospital insurance benefits, supplementary medical

insurance benefits, and total amount of payment vouchers.

Disposition: Once the freeze is lifted, destroy after a total retention of 6 years and 3 months or

after HHS audit and final settlement, whichever is later.

9. A/B MAC or DME MAC Payment Vouchers and Transmittal Files (FROZEN - DO

NOT DESTROY)

These files consist of form TSF-5805, Request for Funds, and similar documents prepared by the

A/B MAC (B) or DME MAC’s servicing bank to obtain Federal funds for benefits paid in

administering medical insurance benefit programs. Also included is Form CMS-1521, Payment

Voucher on Letter of Credit Transmittal, a transmittal that forwards information on request for

funds to CMS and shows the purpose for which funds were drawn, i.e., SMI benefits and total

amount of payment vouchers.

Disposition: Once the freeze is lifted, destroy after a total retention of 6 years and 3 months or

HHS audit and final settlement, whichever is later.

10. A/BMAC (A) or (HHH) Monthly Financial Report Files

These are reports submitted monthly to provide CMS with the basic data to reconcile CMS's

accounts with those that contractors maintain. Included are Form CMS-1522, Monthly

Intermediary Financial Report and attachments.

Disposition: Destroy after HHS audit and final settlement.

11. A/B MAC (B) or DME MAC Performance Report Files

These consist of Forms CMS-1565, Health Insurance for the Aged Program Carrier Performance

Reports, and equivalent documents prepared monthly summarizing each A/B MAC (B) or DME

MAC’s performance in processing claims. The information provides management information

needed for budgeting, financing, work planning, performance evaluation, and identifying

operating problems.

Disposition: Destroy after 3 years.

12. Ambulance Supplier Certification Files

These consist of certifications of suppliers of ambulance services.

Disposition: Destroy 1 year from the end of the year when certification requirements are no

longer met.

13. Requests for Assistance from District Offices (DOs) (FROZEN - DO NOT DESTROY)

These consist of correspondence and forms submitted to the DO for development of additional

information or documents relating to a Medicare claim, e.g., incorrect name or Medicare

beneficiary identifier and similar errors that prevent the processing of a claim.

Disposition: Once the freeze is lifted, dispose of in accordance with instructions for claims

records.

14. A/B MAC (A) or (HHH) Workload Reports Files

These consist of monthly statistical reports on the status of A/B MAC (A) or (HHH) workloads

used by CMS to identify basic management data needed for budgeting, financing, work planning,

and progress evaluation. Included is Form CMS-1566, Health Insurance for the Aged Program

FI Workload Report, or equivalent documents.

Disposition: Destroy after 3 years.

15. Overpayment and Duplicate Charge Detection Activity Report Files - A/B MAC (B) or

DME MAC Report

These consist of quarterly reports summarizing overpayment and duplicate charge detection

activity. They are used to tabulate data on the number of cases in which overpayments are

recovered, the total dollar amount of money overpaid, causes of overpayments, number of

duplicated charges detected, and similar information.

Disposition: Destroy after 3 years.

16. Medicare Beneficiary Correspondence Files (FROZEN - DO NOT DESTROY)

These accumulate as a result of inquiries and complaints received by CO, RO, and contractors

and do not include any correspondence that is related to a claim file.

Disposition: Destroy 3 months after the date of the response to the correspondence. If a response

is not required, the contractor destroys the material 3 months after the date of the

correspondence.

Where the material documents a specific claim, appeal, or similar case, the contractor follows the

instructions for claims records.

17. MAC Contract Files

These consist of agreements entered into with MACs by the Secretary under the provisions of

§§1816 and 1842 of the Act by which MACs agree to perform certain functions in administering

the Hospital Insurance and Supplementary Medical Insurance programs. As such, they provide

basic documentation of the manner in which these programs are implemented. Included are

modifications and amendments.

Disposition: Destroy 3 years after supersession or termination, as applicable.

18. MAC Subcontract Files

These consist of copies of MAC agreements with subcontractors regarding performance of an

audit of providers' costs A/B MAC (A) or (HHH), leases for building space, equipment, and

consulting and other services. Included are CMS approvals, amendments, and similar papers.

Disposition: Destroy 3 years after termination of agreement.

19. Contract Performance Review Visit Files

These consist of documents relating to scheduled or special visits to Medicare contractors to

review your Medicare operations, to determine the degree of adherence to established policy and

adequacy of service to the public, and to verify the accuracy of reporting. Included are reports of

staff visits, follow-up reports, communications concerning improvements in operations, and any

other related documents.

Disposition: Destroy 4 years after the close of the calendar year in which action on the review is

completed.

20. MAC Computer Printout Records (FROZEN - DO NOT DESTROY)

These consist of computer printouts used in processing, paying, and controlling Medicare claims.

a. Pending and process listing, payment listing, duplicate check control, master file update

control, and profiles of physicians and other suppliers of services.

Disposition: Once the freeze is lifted, destroy 4 years after the close of the calendar year in

which payment was made.

b. Check listing and bank reconciliation.

Disposition: Once the freeze is lifted, destroy 6 years after the close of the calendar year in

which paid or voided.

c. CWF inquiry or response listings, transaction listing, activity listings, posting exceptions,

analysis of posting errors, claims inventory control, edit input transactions, and aging of

open claims.

Disposition: Once the freeze is lifted, destroy 3 years after processing. (Contractors with

the capability of electronically retaining the CWF data may destroy the paper copies after

the tapes have been verified.)

21. A/B MAC (A) or (HHH) Cost Report Files (FROZEN - DO NOT DESTROY)

These consist of cost reports submitted by providers to A/B MACs (A) or (HHH) for

determining Medicare reimbursable costs in accordance with regulations and the principles of

reimbursement. The cost report file includes: (a) a copy of the original cost report form as filed

by the provider; (b) copies of all decisions made by field auditors, including those subsequently

reversed by senior auditors; (c) a copy of the Audit Adjustment Report; (d) a copy of revised cost

report schedules (or a revised cost report); (e) a copy of the notice of program reimbursement; (f)

a copy of the audit report when prepared by the A/B MAC (A) or (HHH) staff accountants and

the supporting audit working papers.

Disposition: The A/B MAC (A) or (HHH) maintains the cost report on premises for 3 years after

the Notice of Amount of Medicare Program Reimbursement has been issued to the provider, and

then transfers cost report to inactive storage. Once the freeze is lifted, destroy the cost report

files 5 years after receipt.

(Exception: A cost report file that is the subject of an appeal, litigation, or any other

administrative proceedings, e.g., collection of outstanding overpayments or bankruptcies is not

sent to inactive storage until the case has been settled or closed and all the review and appeal

procedures have been exhausted.)

22. MAC Closing Agreements

These files contain the accepted final settlement for all MAC costs of administration and consist

of the closing agreement, appendix, and schedules of balances due the MAC or Secretary.

Disposition: The MAC cuts off files at the end of the fiscal year. It holds the file in office 1 year

after HHS audit and final settlement then transfers to inactive storage. Destroy these 10 years

after HHS audit and final settlement.

23. Medicare Data Match Files (FROZEN - DO NOT DESTROY)

Questionnaires, case files, employer records and data match records.

Disposition: Cutoff files at the end of the calendar month and transfer to an offsite storage

facility. Once the freeze is lifted, destroy 6 years and 3 months after cutoff.

24. Initial Enrollment Questionnaire (FROZEN - DO NOT DESTROY)

Questionnaires sent to newly enrolled Medicare beneficiaries to obtain information on whether

the individual is covered under a primary insurance plan.

Disposition: Once the freeze is lifted, destroy/delete when 5 years old.

25. Provider Statistical and Reimbursement Reports (PS&RR) - (FROZEN - DO NOT

DESTROY)

These files consist of EDP printouts or microforms showing summaries of payments to hospitals,

skilled nursing facilities, home health agencies, and other providers of service. They are used to

effect cost settlements between the A/B MACs (A) or (HHH) and the providers for program

validation purposes and to determine accuracy of cost reports. These reports contain Part A and

Part B inpatient and outpatient information, inpatient statistics, total bills, covered costs, and

other related data.

Disposition: Once the freeze is lifted, destroy 5 years after completion of audit and/or settlement

process for provider cost report for corresponding fiscal year.

26. A/B MAC (B) or DME MAC Claims Processing File

Consists of documents relating to Part B A/B MAC (B) or DME MAC performance. Submitted

on a weekly basis electronically to CMS’s data center.

Disposition: Destroy after 6 months.