CMS Pub. 100-06, ch. 5, § 410.9

(Rev. 50, 07-30-04)

Exhibit 2 displays reporting requirements for all CMS unsolicited/voluntary refund

checks. The contractor shall report all unsolicited/voluntary refunds from

providers/physicians/suppliers, and other entities identified on the OIG Web site, in

addition to those that identify themselves as having a CIA, OIG Self-Disclosure Protocol,

and/or straight refund. The following data shall be captured: the

provider/physician/supplier, or other entity’s name(s), provider number(s) Tax ID(s),

reason code for refund, number of refund checks, and the total dollar amount of refund

checks. Reason code #16 shall be used to identify that no reason was provided for the

refund.

The contractor is not required to list each check received for the quarter individually, but

may total all the checks on one line for the same provider/physician/supplier. Therefore,

multiple checks for the same provider/physician/supplier when totaled shall be grouped

by like categories for the following:

1. Same Provider/Physician/Supplier

2. Same Reason Code

3. CIA category

4. Self-Disclosure category

5. Straight Refund category

Example 1: Ten checks totaling $100.00 are received from Dr. X for Reason Code 02, but

5 checks are under a CIA and 5 checks are a straight refund.

Exhibit Columns:

Column 1, Provider/Physician/Supplier or Other Entity Name(s): Dr. X

Column 2, Provider/Physician/Supplier Number(s): 99999

Column 3, Tax ID Numbers: 9999999999

Column 4, Reason Codes: 02

Column 5, Line 1 CIA, SDP, Straight Refund: CIA

Column 5, Line 2 CIA, SDP, Straight Refund: Straight Refund

Column 6, Line 1 Total Number of Refund Checks: 5

Column 6, Line 2 Total Number of Refund Checks: 5

Column 7, Line 1 Total Amount of Refunds: $50.00

Column 7, Line 2 Total Amount of Refunds: $50.00

Example 2: Ten checks totaling $100.00 are received from Dr. Y, 8 checks are for

Reason Code 02 and 5 of these checks are a CIA and 3 are a straight refund, 2 checks are

for Reason Code 03 and 1 check is a CIA and 1 check is a straight refund.

Exhibit Columns:

Column 1, Provider/Physician/Supplier or Other Entity Name(s): Dr. Y

Column 2, Provider/Physician Supplier Number9s): 99999

Column 3, Tax ID Numbers: 9999999999

Column 4, Line 1 Reason Codes: 02

Column 4, Line 2 Reason Codes: 02

Column 4, Line 3 Reason Codes: 03

Column 4, Line 4 Reason Codes: 03

Column 5, Line 1 CIA, SDP, Straight Refund: CIA

Column 5, Line 2 CIA, SDP, Straight Refund: Straight Refund

Column 5, Line 3 CIA, SDP, Straight Refund: CIA

Column 5, Line 4 CIA, SDP, Straight Refund: Straight Refund

Column 6, Line 1 Total Number of Refund Checks: 5

Column 6, Line 2 Total Number of Refund Checks: 3

Column 6, Line 3 Total Number of Refund Checks: 1

Column 6, Line 4 Total Number of Refund Checks: 1

Column 7, Line 1 Total Amount of Refunds: $40.00

Column 7, Line 2 Total Amount of Refunds: $20.00

Column 7, Line 3 Total Amount of Refunds: $20.00

Column 7, Line 4 Total Amount of Refunds: $20.00