CMS Pub. 100-04, ch. 30, § 140.6.2

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.

Include in the notice to the physician the following:

• The patient’s name and Medicare beneficiary identifier;

• A description of the service by procedure code, date and place of service, and

amount of the charge;

• The same denial notice included on the beneficiary’s MSN; and

• Depending on whether the beneficiary submitted a copy of an acceptable ABN

with his/her claim, include in the notice to the physician one of the following:

Notice 1 - Advance Beneficiary Notice Received Prior to Initial Determination

(The service identified above has been denied because/although payment

has been made to the patient for a less extensive service,) the information

furnished did not substantiate the need for the (more extensive) service.

Since you informed the beneficiary in writing prior to furnishing the

service that Medicare was likely to deny payment for the (more extensive)

service and the beneficiary signed a statement agreeing to pay, the

beneficiary is liable for (this/the more extensive) service.

Or

Notice 2 - Advance Beneficiary Notice Not Submitted

(The service identified above has been denied because/Although payment

has been made to the patient for a less extensive service,) the information

furnished did not substantiate the need for the (more extensive) service).

If you have collected (any amount from the patient/any amount that

exceeds your maximum allowable actual charge (MAAC) for the less

extensive service), the law requires you to refund that amount to the

patient within 30 days of receiving this notice. The law permits exceptions

to this refund requirement in two cases:

• If you did not know, and could not have reasonably been

expected to know, that Medicare would not pay for this

service; or

• If you notified the beneficiary in writing before providing

the service that you believed that Medicare was likely to

deny the service, and the beneficiary signed a statement

agreeing to pay for the service.

If you come within either exception, or if you believe the contractor was

wrong in its determination that Medicare does not pay for this service, you

should request an appeal of this determination by the contractor within 30

days of receiving this notice. Your request for appeal should include any

additional information necessary to support your position.

If you request an appeal within this 30 day period, you may delay

refunding the amount to the beneficiary until you receive the results of the

appeal. If the appeal determination is favorable to you, you do not have to

make any refund. If, however, the appeal is unfavorable, the law specifies

that you must make the refund within 15 days of receiving the unfavorable

appeal decision.

The law also permits you to request an appeal of the determination at any

time within six months of receiving this notice. An appeal requested after

the 30 day period does not permit you to delay making the refund.

Regardless of when an appeal is requested, the patient will be notified that

you have requested one, and will receive a copy of the determination.

The patient has received a separate notice of this denial decision. The

notice advises that he or she may be entitled to a refund of any amounts

paid, if you should have known that Medicare would not pay and did not

tell him or her. It also instructs the patient to contact your office if he or

she does not hear anything about a refund within 30 days.

The requirements for refund are in §1842(1) of the Social Security Act.

Section 1842(1) specifies that physicians who knowingly and willfully fail

to make appropriate refunds may be subject to civil money penalties

and/or exclusion from the Medicare program.

If you have any questions about this notice, please contact (Contractor

contact, telephone number).

The contractor will ensure that the telephone number puts the physician in touch with a

knowledgeable professional who can discuss the basis for the denial or reduction in

payment.

NOTE: These procedures do not apply to claims the contractor automatically denies

under the A/B link procedures. In those cases, the QIO is responsible for notifying the

beneficiary and physician of the refund requirements of §1842(1) and making the refund

determination where appropriate.