US · guidance
CMS Pub. 100-08, ch. 8, § 8.4.4.4.3
Worksheets
The contractor shall maintain any formal worksheets used by reviewers. The worksheets
may include, but are not limited to data and information, such as:
• Name and identification number of the provider or supplier;
• Name and title of reviewer;
• The HICN/MBI, the unique claim identifier (e.g., the claim control number), and
the line item identifier;
• Identification of each sampling unit and its components (e.g., UB-92 or attached
medical information);
• Stratum and cluster identifiers, if applicable;
• The amount of the original submitted charges (in column format);
• Other information required by cost report worksheets in Pub. 100-08, Exhibits 9
through 12;
• The amount paid;
• The amount that should have been paid (either over or underpaid amount); and
• The date(s) of service.
History
(Rev. 906; Issued: 09-26-19; Effective: 01-02-19; Implementation: 01-02-19)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
a484c3f593193e724e3ccd941da5d2d6432528841d45813c502eede8662825ec
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