CMS Pub. 100-08, ch. 5, § 5.6

and/or Civil Monetary Penalty (CMP) When Invalid CMNs or DIFs Are

Identified

(Rev. 10749; Issued: 05-11-21; Effective: 06-11-21; Implementation: 06-11-21)

Section 1862(a)(1)(A) of the Act prohibits Medicare payment for services that are not

reasonable and necessary. Section 1833(e) of the Act requires that Medicare be furnished

by providers and suppliers "such information as may be necessary in order to dete rmine

the amount due.…" These sections provide support that a failure to have a valid CMN or

DIF on file or to submit a valid CMN or DIF to the DME MACs or UPICs makes the

underlying claim improper because Medicare does not have sufficient information to

determine whether the claim is reasonable and necessary. A valid CMN is one in which

the treating physician has attested to and signed supporting the medical need for the item,

and the appropriate individuals have completed the medical portion of the CMN. A valid

DIF is one in which the supplier has attested to and signed supporting the medical need for

the item. When the DME MACs and UPICs identify a claim for which a CMN or DIF is

not valid, they may deny the claim and/or initiate overpayment action.

If a DME MAC or UPIC identifies a supplier that has a pattern of improperly completing

the CMN or DIF, the DME MAC or UPIC may choose to initiate a potential Civil

Monetary Penalty (CMP) case against the supplier. The authority for such action is found

in §1834(j)(2)(A)(iii) of the Act which states that "any supplier of medical equipment and

supplies who knowingly and willfully distributes a CMN in violation of clause (I) or fails

to provide the information required under clause (ii) is subject to a civil money penalty in

an amount not to exceed $1,000 for each such certificate of medical necessity so

distributed." The provisions of §1128A of the Act (other than subsections (a) and (b) shall

apply to CMPs penalties under this subparagraph in the same manner as they apply to a

penalty or proceeding under §1128(A)(a)) of the Act.