Medicare_Carriers_Manual / 14009 / 14009

Why This Topic Matters

It helps readers understand the type of case information Medicare contractors are expected to compile when forwarding a matter for possible investigative action. The article is relevant to staff handling complaint development, documentation, and referral workflows.

Article Sections

1. 14009. OI Case Summary and Referral Format

   Describes the overall format for preparing a referral summary and the categories of information to include. It also notes where the guidance originated and how the referral materials should be retained.

2. Case Referral Fact Sheet Format

   Lists the major administrative fields used to identify the subject, allegation, source of complaint, investigator contact details, address information, and related case data. The section focuses on the structure of the referral packet.

3. Case Summary Format

   Outlines the narrative elements to be included in the case summary, including complaint source, citation references, overpayment information, billing data, and related supporting material. It also identifies areas for additional development and background information.

4. Details of Past Complaints

   Addresses how to summarize prior complaint history and related actions when such information has been identified.

5. Detailed Correspondence History with Subject

   Covers documentation of direct correspondence with the subject and related communication history. It also notes the need to alert investigators to external interest or publicity concerns.

6. Other Agencies Involved

   Explains how to note referrals or investigations involving other agencies and when that information should be included.

7. Other Pertinent Information

   Lists additional contextual items that may help evaluate the case, such as organizational relationships, filing history, appeals activity, and peer-comparison review areas.

8. Complaints by Current or Former Employees

   Highlights a special consideration for complaints originating from current or former employees and the possibility of limited internal development.

9. List of Attachments

   Provides closing guidance on attachments, coordination across network entities, and retention of the completed summary in the case file.