CMS Pub. 100-04, ch. 30, § 30.2.2

Knowledge

(Rev.: 4197; Issued: 01-11-19; Effective: 04-15-19; Implementation: 04-15-19)

The healthcare provider or supplier is also accountable for information contained in the

beneficiary’s medical records, such as the beneficiary’s medical chart, attending

physicians’ notes, or similar records. When the medical records clearly show that the

beneficiary received only non-covered services as described in the Medicare Benefit

Policy Manual, the healthcare provider or supplier will be presumed to have knowledge

of non-coverage.

Examples:

• A physician clearly indicated in the beneficiary’s medical record that the patient

no longer needed the services or the level of care provided;

• The physician indicated the patient could be discharged;

• The attending physician refused to certify or recertify the beneficiary’s need for a

particular level of care covered by Medicare because he/she determined that the

patient does not require a covered level of care; or

• The contractor requested additional medical evidence after a certain number of

days to determine whether continued coverage is warranted. However, the

healthcare provider or supplier did not submit the evidence within the stipulated

time.