CMS Pub. 100-06, ch. 5, § 410.6

When Identifying Information is not Provided

(Rev. 315, Issued: 05-17-19, Effective: 06-18- 19, Implementation: 06-18-19)

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.

After depositing unsolicited/voluntary refund checks in accordance with section 410.4

above, Medicare contractors shall do the following:

For Non-MSP Checks

1) If no specific Patient/Medicare beneficiary identifier information was provided

with the unsolicited/voluntary refund, the contractor shall contact the

provider/physician/supplier, or other entity sending the refund check for further

information. Exhibit 1 (overpayment refund) contains the minimum claim

specific data necessary to process the refund. The contractor should use this

form during phone inquiry or attach it to a letter to the

provider/physician/supplier requesting further information regarding the

submitted refund.

2) When there is no identifying information provided, the contractor shall perform

the research necessary to obtain the minimum data required to meet the

reporting requirements in Exhibit 2 (Summary Report). If the information is

being collected via a telephone inquiry, the contractor employee conducting the

inquiry shall inform the provider/physician/supplier, or other entity verbally that

if the specific Patient/ Medicare beneficiary identifier information is not

provided, no appeal rights can be afforded.

The minimum reporting data shall include:

a. Provider/physician/supplier, or other entity’s name, number, and Tax ID

number.

b. Identification of whether the provider/physician/supplier, or other entity

has a CIA with the OIG or are under the OIG Self-Disclosure Protocol;

and whether it is a straight refund (i.e., a provider not under a CIA or OIG

Self-Disclosure Protocol).

c. The reason(s) for each refund.

d. The total number of refund checks (in the case of a check with multiple

providers/reason codes, each instance shall be counted separately).

e. The total dollar amount of refunds.

3) Medicare contractors shall have 60 days from deposit of the check to obtain the

minimum claim specific data required to apply the check. The contractor shall

take at least one documented follow-up action during the 60-day period to

obtain the data.

4) If the minimum claim specific data required to apply the refund is obtained

from the provider/physician/supplier, or other entity within 60 days from the

check’s date of deposit, the contractor shall make/initiate any appropriate

adjustments to the identified claims and/or the claim history file for the amount

of the refund. The contractor shall establish an account(s) receivable and apply

the balance of the check to the account(s) receivable from the “Other

Liabilities” account within 60 days after the deposit of the voluntary refund.

The contractor shall ensure that any Remittance Advice or MSN generated as a

result of the claim adjustment contains the appropriate appeals language, if

applicable.

5) If the minimum claim specific data required to apply the refund is not obtained

from the provider/physician/supplier, or other entity within 60 days from the

check’s date of deposit, the “Other Liabilities” account shall be reduced and an

accounts receivable due to a straight refund shall be established for the amount

of the unapplied unsolicited/voluntary refund. All Medicare systems shall allow

contractors the ability to set up accounts receivable using either the

provider/physician/supplier, or other entity or beneficiary number.

6) In both instances, the Medicare contractor shall establish an accounts receivable

in the Medicare system that shall be recognized on line 2a, New Accounts

Receivable on Form CMS-751 report within 60 days after the deposit of the

voluntary refund. In addition, the Medicare contractor shall perform a

simultaneous transaction to apply the refund to the established accounts

receivable and recognize the collection on line 4a, Cash/Check Collections on

Form CMS-751 report.

7) The accounts receivable shall be established using the last name of the debtor

identified on the check, as well as the debtor’s employer/tax identification

number and/or provider or beneficiary number. If the debtor’s employer/tax

identification number or provider or beneficiary number is unavailable, then the

first four letters of the debtor’s name and last four digits of the bank account

number on the check shall be used as identifying information for setting up the

accounts receivable. All Medicare systems shall have the ability to manually

complete this procedure.

8) If the amount of the unsolicited/voluntary refund check exceeds the amount of

the original claim, Medicare contractors shall check all categories of open

account(s) receivable for that provider/physician/supplier including those

established as a result of medical review, BI review, cost reports, other

overpayment demands, and MSP demands. If an outstanding receivable is

identified, the contractor shall apply the remaining amount of the

unsolicited/voluntary refund to the outstanding receivable balance. If there are

multiple outstanding accounts receivables, then the excess funds should be

applied to the oldest accounts receivable first – interest then principal.

9) Medicare contractors shall not automatically refund excess recoupments to the

provider/physician/supplier, or other entity. Contractors shall only refund

excess recoupments when no other outstanding accounts receivable exists, or

written documentation/evidence clearly supports that Medicare is not entitled to

the money or was not the intended recipient of the refund check.

10) The Medicare contractor shall be responsible for ensuring the completion of

Exhibit 1 (or facsimile thereof) and reporting it on Exhibit 2 upon final

disposition of the unsolicited/voluntary refund (i.e., after investigation of the

origin of the refund).

11) Contractors are not required to report the established accounts receivable on the

PSOR. (This requirement does not preclude the contractor from reporting the

receivable on the PSOR if current systems already do so.)

For MSP Checks

1) The Medicare contractor shall determine if there is an existing case and/or

accounts receivable. If this is an existing case and/or accounts receivable, the

contractor shall follow normal recovery procedures. If there is no case and/or

accounts receivable, and there is indication of MSP involvement, the contractor

shall send an MSP inquiry via the Electronic Correspondence Referral System

(ECRS) to the MSP Coordination of Benefits Contractor (COBC) within 20

days from the check’s date of deposit. The 45-day correspondence timeframe is

not appropriate for addressing checks either solicited or unsolicited.

Contractors shall identify checks during the initial mail sort and place a priority

on their resolution and distribution. When referring information to the COBC

for MSP investigation, the contractor shall forward all pertinent data. All

fields on the ECRS Inquiry screen shall be completed if the data is

available on the returned check or any accompanying correspondence.

Information in the informant fields such as telephone numbers, point of

contact, etc. are critical to COBC development efforts.

2) Medicare contractors shall only allow 100 days from the date of the ECRS

inquiry for a response from the COBC before taking action with respect to the

“unapplied receipts.” This time period will also allow for the COBC to develop

the case. If additional information is obtained after the initial inquiry that would

help facilitate the processing and research of information, the COBC Consortia

Representative shall be contacted and provided the additional information, via

fax or telephone, to assist in completing the research. The contractor shall not

send a second ECRS inquiry. A total of 120 days from the check’s date of

deposit will be allowed to bring closure to the unapplied receipt.

3) If the minimum reporting information from the MSP COBC is provided within

100 days from the initial ECRS inquiry, the contractor shall make/initiate any

appropriate adjustments to either the identified claims and/or the claim history

file for the amount of the refund, depending on the entity making the refund and

the purpose of the refund. The Medicare contractor shall establish an account(s)

receivable and apply the balance of the check to the account(s) receivable from

the “Other Liabilities” account. If as a result of applying the voluntary refund

the contractor identifies additional dollars specific to the issue in CWF, a

demand letter shall be sent for the remaining amount owed.

4) If, within 100 days from the initial ECRS inquiry, 1) the minimum reporting

information is not provided, 2) a response has not been received from the MSP

COBC, or 3) a response from the COBC indicates they could not obtain a

response (e.g., CM Code 62), Medicare contractors shall establish an accounts

receivable and apply the balance of the check to the account(s) receivable from

the “Other Liabilities” account. For COBC no response codes specific to a

provider/physician/supplier unsolicited/voluntary refund, contractors should do

the full claim adjustment but use a non-MSP reason (i.e., billed in error), which

would then not need an MSP record to be established on CWF. The contractor

shall report the refund in Exhibit 2 (Unsolicited/Voluntary Refund - Summary

Report), and annotate with reason code 16. In addition, Exhibit 1 and/or the

contractor’s supporting documentation shall specify the refund as received with

no reason for refund and/or no MSP response.

5) The Medicare contractor shall establish an accounts receivable in the Medicare

system and that shall be recognized on line 2a, New Accounts Receivable on

Form CMS-M751 report within 100 days after the initial ECRS inquiry. In

addition, the Medicare contractor shall perform a simultaneous transaction to

apply the refund to the established accounts receivable and recognize the

collection on line 4a, Cash/Check Collections on Form CMS-M751 report. The

contractor shall initiate normal MSP recovery action for any remaining

outstanding balance owed.

6) The accounts receivable shall be established using the last name of the debtor

that issued the check or on whose behalf the check was issued, as well as the

debtor’s employer/tax identification number and/or provider or beneficiary

number. If the debtor’s employer/tax identification number or provider or

beneficiary number is unavailable, then the first four letters of the debtor’s name

and last four digits of the bank account number on the check shall be used as

identifying information for setting up the accounts receivable. All Medicare

systems shall have the ability to manually complete this procedure.

7) If the amount of the unsolicited/voluntary refund check exceeds the amount of

the original claim, Medicare contractors shall check all categories of open

account(s) receivable for that provider/physician/supplier or other entity

including those established as a result of medical review, BI review, cost

reports, other overpayment demands. If an outstanding receivable is identified,

the contractor shall apply the remaining amount of the unsolicited/voluntary

refund to the outstanding receivable balance. If there are multiple outstanding

accounts receivables, then the excess funds should be applied to the oldest

accounts receivable first – interest then principal.

8) Medicare contractors shall not automatically refund excess recoupments to the

provider/physician/supplier, or other entity. Contractors shall only refund

excess recoupments when no other outstanding accounts receivable exists, or

written documentation/evidence clearly supports that Medicare is not entitled to

the money or was not the intended recipient of the refund check. Contractors

shall follow the non-MSP provider/physician/supplier refund process when

encountering MSP provider/physician/supplier unsolicited/voluntary refunds.

Monies voluntarily sent in from beneficiaries (or a representative of) and/or

insurers or other third party payers may be refunded only if COBC determines,

after 100 days, no issue exists or an issue exists which results in the lead

contractor identifying Medicare’s claim to be less than the refunded amount.

For example, many times an attorney may remit payment for the total

conditional amount prior to a formal demand.

9) The Medicare contractor shall be responsible for ensuring the completion of

Exhibit 1 (or facsimile thereof) and reporting it on Exhibit 2 upon final

disposition of the unsolicited/voluntary refund (i.e., after investigation of the

origin of the refund).

10) Contractors shall not report the MSP accounts receivable on the PSOR.