CMS Pub. 100-08, ch. 10, § 10.7.18

A. Model Language for §424.516(f)(1) Situations

The contractor shall use the model language below if it is requesting documentation from a

provider or supplier furnishing the items or services addressed in §424.516(f)(1).

“Dear Provider/Supplier:

Under 42 CFR §424.516(f)(1), a provider or supplier that furnishes covered ordered items of

durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), clinical laboratory,

imaging services, or covered ordered/certified home health services is required to:

• Maintain documentation for 7 years from the date of service, and

• Upon the request of CMS or a Medicare contractor, provide access to that documentation.

The documentation to be maintained includes written and electronic documents (including the

National Provider Identifier (NPI) of the physician who ordered/certified the home health

services and the NPI of the physician - or, when permitted, other eligible professional - who

ordered items of DMEPOS or clinical laboratory or imaging services) relating to written orders

and certifications and requests for payments for items of DMEPOS and clinical laboratory,

imaging, and home health services.

Consistent with §424.516(f)(1), please mail to us copies of the orders for the items or services

that were furnished to the following beneficiaries on the dates specified:

(Contractors shall insert the beneficiaries’ names (up to 5 may be listed, unless CMS specifies

otherwise), appropriate identification information, and the dates on which the provider or

supplier furnished the items/services in question. The contractor has the discretion to determine

the cases/services that are included in this documentation request as well as the type(s) of

documentation to be requested.)

The documentation must be received at the following address no later than 30 calendar days after

the date of this letter:

(Cite appropriate address)

Failure to timely submit this documentation may result in the revocation of your enrollment

pursuant to 42 CFR §424.535(a)(10).”

Please contact our office with any questions at [phone number] between the hours of [x:00

AM/PM] and [x:00 AM/PM] and refer to your application(s) reference number [Reference

number]

Sincerely,

[Name]

[Title]

[Company]

B. Model Language for §424.516(f)(2) Situations

The contractor shall use the model language below if it is requesting documentation from a

provider or supplier furnishing the items or services addressed in § 424.516(f)(2).

“Dear Physician/Professional:

Under 42 CFR §424.516(f)(2), a physician who orders/certifies home health services and the

physician - or, when permitted, other eligible professional - who orders items of DMEPOS or

clinical laboratory or imaging services is required to maintain documentation for 7 years from

the date of service and to provide access to that documentation pursuant to a CMS or Medicare

contractor request. The documentation to be maintained includes written and electronic

documents relating to written orders and certifications and requests for payments for items of

DMEPOS and clinical laboratory, imaging, and home health services.

Consistent with §424.516(f)(2), please mail to us copies of the orders for items or services that

you issued for the following beneficiaries on the dates specified:

(Contractors shall insert the beneficiaries’ names (up to 5 may be listed, unless CMS specifies

otherwise), appropriate identification information, and the dates on which the orders were made.

The contractor has the discretion to determine the cases/services that are included in this

documentation request as well as the type(s) of documentation to be requested.)

The documentation must be received at the following address no later than 30 calendar days after

the date of this letter:

(Cite appropriate address)

Failure to timely submit this documentation may result in the revocation of your enrollment

pursuant to 42 CFR §424.535(a)(10).” (For individuals enrolled via the Form CMS-855O, the

contractor shall instead use the following language: “Failure to timely submit this documentation

may result in the revocation of your Form CMS-855O enrollment.”)

Please contact our office with any questions at [phone number] between the hours of [x:00

AM/PM] and [x:00 AM/PM] and refer to your application(s) reference number [Reference

number]

Sincerely,

[Name]

[Title]

[Company]