CMS Pub. 100-04, ch. 30, § 100.3.1

The following types of documentation are sufficient to establish that payment was made

in the amount alleged:

• An itemized bill from the provider, practitioner, or supplier reflecting the items

and services for which the provider, practitioner, or supplier has been found liable

and has received payment along with the payer’s cancelled check, money order

receipt, or statement of receipt from the provider, physician, or supplier;

• A summary bill from the provider, practitioner, or supplier which pertains to the

items and services for which the provider, practitioner, or supplier has been found

liable and has collected from the beneficiary or other person along with the

payer’s cancelled check, money order receipt, or a statement of receipt from the

provider, practitioner, or supplier showing the same total amount;

• The payer’s cancelled check, money order receipt, or the statement of receipt

from the provider, practitioner, or supplier if the contractor’s records reflect the

provider, practitioner, or supplier’s charges for the items and services for which

the provider, practitioner, or supplier has been found liable and these equal the

total of the amount paid; or

• If the requester alleges that the provider, practitioner, or supplier did not furnish

an itemized bill or a receipted statement and no other proof of payment is

available, the contractor obtains a statement on Form SSA-795 to this effect from

all parties involved, including the provider, physician, or supplier if possible. The

statement should describe the circumstances, such as the manner of payment, and

the reasons for not obtaining a receipt or any proof of payment. If there were any

witnesses to the payment, the contractor obtains their statements on Form

SSA-795. The contractor refers any questions as to the acceptability of proof of

payment to the RO.

When the beneficiary or other person on behalf of the beneficiary initially contacts the

SSO, that office sends the statements and evidence relevant to the indemnification claim

to the appropriate contractor. If future contact with the beneficiary or other person is

necessary, the contractor proceeds with a direct contact unless the assistance of the SSO

is needed.