CMS Pub. 100-04, ch. 1, § 70.8.6.1

A. General

Section 1848(g)(4) of the Social Security Act requires physicians and suppliers to submit

claims to Medicare carriers for services furnished on or after September 1, 1990. It also

prohibits physicians and suppliers from imposing a charge for completing and submitting

a claim. Physicians and suppliers who fail to submit a claim or who impose a charge for

completing the claim are subject to sanctions. CMS is responsible for assessing sanctions

and monetary penalties for noncompliance.

Physicians and suppliers are not required to take assignment of Medicare benefits unless

they are enrolled in the Medicare Participating Physician and Supplier Program or, in the

case of physician services, the Medicare beneficiary is also a recipient of State medical

assistance (Medicaid) or the service is otherwise subject to mandatory assignment.

B. Compliance Monitoring

To ensure that providers and suppliers are enrolled in the Medicare program and submit

claims in compliance with the mandatory claims submission requirements found in

§1848(g)(4) of the Social Security Act, contractors shall:

1) Process beneficiary claims submitted to A/B MACs or carriers for services that

are not covered by Medicare (e.g., for hearing aids, cosmetic surgery, personal

comfort services, etc.; see 42 CFR 411.15 for details), in accordance with its

normal processing procedures;

2) Process beneficiary claims submitted to A/B MACs or carriers for services that

are covered by Medicare and the beneficiary has submitted a complete and valid

claim (Form CMS-1490S) and all supporting documentation associated with the

claim, including an itemized bill with the following information:

• Date of service,

• Place of service,

• Description of illness or injury,

• Description of each surgical or medical service or supply furnished,

• Charge for each service,

• The doctor’s or supplier’s name and address,

• The provider or supplier’s National Provider Identifier (NPI)

• The ordering & referring provider’s legal name and address and the National

Provider Identifier (NPI) if known when the itemized bill is from:

A Clinical laboratory for ordered tests

An independent diagnostic imaging center for ordered imaging procedures

A supplier of Durable Medical Equipment, Prosthetics, Orthotics and

Supplies (DMEPOS) for ordered DMEPOS

If the beneficiary furnishes all other information but fails to supply the provider or

supplier’s NPI the contractor shall not return the claim but rather look up the

provider or supplier’s NPI using the NPI registry. If the contractor determines

that the provider or supplier was not a Medicare enrolled provider with a valid

NPI, the contractor shall follow previously established procedures in order to

process and adjudicate the claim.

3) Retain the Form-1490S and supporting documentation and manually return a copy

to the beneficiary if it is for a Medicare-covered service and the claim is

incomplete, does not include all required supporting documentation and/or

contains invalid information. Contractors shall also include an appropriate letter

that specifically communicates all the items listed above which were missing or

invalid. In addition, the CMS-1490S and supporting documentation shall be

maintained for purposes of the timely filing rules in the event that the beneficiary

re-submits the claim.

If the Beneficiary submits a claim on the English or Spanish Form CMS-1490S

(version 01/05) on or after April 1, 2019, manually return the Form CMS-1490S

(version 01/05) claim to the beneficiary, and include a copy of the Form CMS-

1490S (version 01/18), along with a letter instructing the beneficiary to complete

and return the Form CMS-1490S (version 01/18) for processing within the time

period prescribed in §70.5.

If a beneficiary submits a claim on the Form CMS-1500, manually return the

Form CMS-1500 claim to the beneficiary, and include a copy of the Form CMS-

1490S, along with a letter instructing the beneficiary to complete and return the

Form CMS-1490S for processing within the time period prescribed in §70.5,

above. Include in the letter a description of missing, invalid or incomplete items

required for the Form CMS-1490S that were not included with the submitted

Form CMS-1500 or were invalid.

4) Retain Medicare claims records using the following disposition rules.

DISPOSITION:

1. Carriers who Microform Claims

a) Hardcopy Records - Cut off no later than the close of the calendar year (CY) in

which paid. The hardcopy claim must be retained in accordance with the

following:

(1) If a corresponding master microfilm has been made and verified, transfer to a

Federally-approved records storage facility or hold onsite. Destroy after a total

retention of 3 years after the close of the CY in which paid.

(2) If a corresponding master microform record has NOT been made and verified,

transfer to a Federally-approved records storage facility or hold onsite. Destroy

after a total retention of 6 years and 3 months after the close of the CY in which

paid.

b) Microform Records

The master microform record must be retained for a total retention of 6 years and

3 months following the close of the calendar year in which paid.

2. Carriers Who Do Not Microfilm Claims Records

Cut off at the close of the calendar year (CY) in which paid, then transfer to a

Federally-approved records storage facility. Destroy after a total retention of 6

years and 3 months. Earlier cutoff and transfer is authorized. However, the

records must be retained for a total retention of 6 years and 3 months following

the close of the calendar year in which payment is made.

a) Hardcopy Records - The hardcopy must be retained onsite until the microform

has been verified. Cut off at the close of the calendar year in which paid; transfer

hardcopy to a Federally-approved records storage facility only if there is a

corresponding master microfilm record that can be retained for the period

indicated in b. below; otherwise, the hardcopy shall be retained until the 6 years

and 3 months period is reached. Earlier cutoff and transfer is authorized.

However, the hardcopy must be retained for a total retention of 3 years after the

close of the calendar year in which paid.

b) Microform Records - The master microform records must be retained for a

total retention of 6 years and 3 months following the close of the calendar year in

which payment is made.

When returning a beneficiary submitted claim, the contractor shall inform the beneficiary

that the provider or supplier is required by law to submit a claim on behalf of the

beneficiary (for services that would otherwise be payable), and that in order to submit the

claim, the provider or supplier must enroll in the Medicare program. In addition,

contractors shall encourage beneficiaries to always seek non-emergency care from a

provider or supplier that is enrolled in the Medicare program.

If a beneficiary receives services from a provider or supplier that refuses to submit a

claim to the A/B MAC or carrier, on the beneficiary’s behalf, (for services that would

otherwise be payable by Medicare), and/or refuses to enroll in the Medicare program, the

beneficiary should:

(1) Notify the contractor in writing that the provider or supplier refused to submit a

claim to Medicare and/or refused to enroll in Medicare, and

(2) Submit a complete Form CMS-1490S with all supporting documentation.

The contractor shall process and pay the beneficiary’s claim if it is for a service that

would be payable by Medicare were it not for the provider or supplier’s refusal or

inability to submit the claim and/or enroll in Medicare. Claims shall be adjudicated

based on whether the service provided is covered or non-covered/excluded rather than on

the provider’s enrollment status. If for a covered service, the claim shall be processed and the

allowed amount reimbursed to the beneficiary, if appropriate. If for a non-covered/excluded service,

the claim shall be processed and denied with an appropriate MSN message. For

sanctioned/excluded and opt-out physicians/practitioners the following MSN messaging is

recommended:

Sanctioned/Excluded provider or supplier:

A sanctioned or excluded provider or supplier is an individual or business excluded from

participation in the Medicare program for a stated period of time as a result of fraudulent

activity, program abuse, or impermissible conduct as determined by OIG. CMS will pay

the first claim submitted by a beneficiary for the services of a sanctioned/excluded

physician or practitioner and immediately notify the sanctioned/excluded physician or

practitioner of the exclusion. CMS will not pay a claim for sanctioned/excluded

physician or practitioner services more than 15 days after the date on the notice to the

physician or practitioner, or after the effective date of the exclusion, whichever is later.

Under no circumstance may Medicare payment be made to any entity, including

beneficiaries, for services rendered by such providers or suppliers after the first claim is

paid. An example of language that may be considered:

MSN Message 21.27

English

Services provided by a Medicare sanctioned/excluded provider or supplier. No Medicare

payment may be made.

Spanish

Los servicios fueron brindado por un proveedor excluído de Medicare, por lo tanto

Medicare no pagó por los servicios.

Opt-Out physicians and practitioners:

Medicare payment may be made for the claims submitted by a beneficiary for the

services of an opt out physician or practitioner when the physician or practitioner did not

privately contract with the beneficiary for services that were not emergency care services

or urgent care services and that were furnished no later than 15 days after the date of a

notice by the carrier that the physician or practitioner has opted out of Medicare (see 42

C.F.R. 405.435(c)). Therefore, if the beneficiary submits a claim for a service that was

furnished by an opt out physician or practitioner, then the carrier must contact the opt out

physician or practitioner in order to ascertain whether the beneficiary entered into a

private contract with the opt out physician or practitioner. (Note: The carrier should

obtain a copy of the private contract from the opt out physician/practitioner before

denying the beneficiary’s claim if the beneficiary did, in fact, enter into a private contract

with the physician or practitioner.) If the beneficiary did not enter into a private contract

with the physician or practitioner and the beneficiary did not receive notice from the

carrier that the physician opted out of Medicare, then Medicare payment may be made to

the beneficiary for the non-emergency and/or non-urgent care services (assuming that the

services would otherwise be payable). On the other hand, if the beneficiary did enter into

a private contract with the physician or practitioner for the services or received services

from the physician/practitioner 15 days after the date of a notice by the carrier that the

physician or practitioner has opted out of Medicare, then no Medicare payment may be

made. Medicare has instructed opt out physicians and practitioners that private contract

language must include beneficiary instruction precluding the beneficiary from billing

Medicare for these services. An example of language that may be considered:

MSN Message 21.26

English

Claim denied because services were provided by an Opt-Out physician or practitioner.

No Medicare payment may be made.

Spanish

La reclamación fue denegada porque los servicios fueron brindados por un médico ó

proveedor que decidió no participar en Medicare, por lo tanto, Medicare no pagó por los

servicios.

Contractors shall maintain documentation of beneficiary complaints involving violations

of the mandatory claims submission policy and a list of the top 50 violators, by State, of

the mandatory claim submission policy.

Contractors are encouraged to educate providers and suppliers that they must be enrolled

in the Medicare program before they submit claims for services furnished or supplied to

any Medicare beneficiary.

The above policy, including the NPI requirement, is not applicable for foreign beneficiary

claims submitted for covered services. These claims should be processed using

guidelines for foreign claims.

The above policy, including the NPI requirement, is not applicable to beneficiary claims

submitted to DMEMACs for durable medical equipment, prosthetics, orthotics, and

supplies. These claims should be processed by DMEMACs using current procedures.

C. Exception When Physician, Other Practitioner, or Supplier Is Excluded From

Participating in Medicare Program

Section 1848(g)(4) of the Social Security Act requires physicians, other practitioners, or

suppliers to submit claims to Medicare carriers for services furnished after September 1,

1990. This does not apply to physicians, other practitioners, or suppliers who have been

excluded from participating in the Medicare program. Physicians, other practitioners,

and suppliers who have been excluded from the Medicare program are prohibited from

submitting claims or causing claims to be submitted. See the Medicare Program Integrity

Manual for procedures concerning claims submitted by an excluded practitioner, his/her

employer, or a beneficiary for services or items provided by an excluded physician, other

practitioner, or supplier. Carriers must maintain the systems capability to identify claims

submitted by excluded physicians, other practitioners, or suppliers as well as items or

services provided, ordered, prescribed, or referred by an excluded party.

When an excluded physician, other practitioner, or supplier has not submitted a claim on

behalf of the beneficiary and/or the beneficiary has submitted the claim themselves, do not

send a notification letter to the physician, other practitioner, or supplier warning of civil

monetary penalties due to noncompliance with §1848(g)(4)(A) of the Act. Instead, follow

the instructions in the Program Integrity Manual.