CMS Pub. 100-04, ch. 30, § 50.16

Prior to submitting any materials to the RO, the Medicare contractor will contact the

RO to determine how to proceed in referring a potential sanction case for violation of

refund requirements. When referring these types of cases to the region, the contractor

should include the following:

Background of the Subject

The subject’s business name, address,

Medicare Identification Number, owner’s

full name and Social Security Number,

Tax Identification Number (if different),

and a brief description of the subject’s

special field of medical equipment,

supplies, or services.

Origin of the Case

A brief description of how the violations

were discovered.

Statement of Facts

A statement of facts in chronological

order describing each failure to comply

with the refund requirements.

Written Correspondence and Written

Summaries

Copies of any meetings or telephone

contacts with the beneficiary and the

supplier regarding the supplier’s failure

to make a refund.

List of the following for each item or

service not refunded to the beneficiary

by the supplier (grouped by beneficiary):

•Beneficiary Name and Medicare

beneficiary identifier;

•Claim Control Number;

•Procedure Code (CPT-4 or HCPCS) of

non-refunded item or service;

•Procedure Code modifier;

•Date of Service;

•Place of Service Code;

•Submitted Charge;

•Units (quantity) of Item or Service; and

•Amount Requested to be refunded.

Additional Information Any information that may be of value to

the RO.