CMS Pub. 100-08, ch. 4, § 4.11.8.1

The following is background information for developing specific CMS CMP cases:

Effective for services or items provided on or after January 1, 1999, §4311 of the

Balanced Budget Act (BBA) provides that Medicare beneficiaries have the right to

request and receive an itemized statement from their health care provider of service (e.g.,

hospital, nursing facility, home health agency, physician, non-physician practitioner,

DMEPOS supplier). Upon receipt of this request, providers have 30 days to furnish the

itemized statement to the beneficiary. Health care providers who fail to provide an

itemized statement may be subject to a CMP of not more than $100 for each failure to

furnish the information (§1806(b)(2)(B) of the Social Security Act). An itemized

statement is defined as a listing of each service(s) or item(s) provided to the beneficiary.

Statements that reflect a grouping of services or items (such as a revenue code) are not

considered an itemized statement.

A beneficiary who files a complaint with a MAC regarding a provider’s failure to

provide an itemized statement must initially validate that his/her request was in writing

(if available), and that the statutory 30-day time limit (calendar days) for receiving the

information has expired. In most cases, an additional 5 calendar days should be allowed

for the provider to receive the beneficiary’s written request. If the beneficiary did not

make his/her request in writing, inform him/her that he/she must first initiate the request

to the provider in writing. It is only after this condition and the time limit condition are

met that the MAC may contact the provider.

Once the MAC confirms that the complaint is valid, the MAC shall initiate steps to assist

the beneficiary in getting the provider to furnish the itemized statement. MACs shall

initiate the same or similar procedures when receiving complaints regarding mandatory

submission of claims (i.e., communicating with the provider about their non-compliance

and the possibility of the imposition of a CMP).

If the intervention of the MAC results in the provider furnishing an itemized statement to

the beneficiary, the conditions for the statute are considered met, and a CMP case should

not be developed. Should the intervention of the MAC prove unsuccessful, the MAC

shall consider referral to the UPIC for subsequent referral of the potential CMP case to

CMS, following the guidelines established in PIM Chapter 4, §§4.11.6.1 and 4.11.7.

There may be instances where a beneficiary receives an itemized statement and the

MAC receives the beneficiary’s request (written or oral) to review discrepancies on

his/her itemized statement. MACs shall follow their normal operating procedures in

handling these complaints. MACs shall determine whether itemized services or items

were provided, or if any other irregularity (including duplicate billing) resulted in

improper Medicare payments. If so, the MAC shall recover the improper payments.