§1806. Explanation of medicare benefits11

Social Security Act

Title XVIII — Health Insurance for the Aged and Disabled

(42 U.S.C. 1395b-7)

(a) In General.-The Secretary shall furnish to each individual for whom payment has been made under this title (or would be made without regard to any deductible) a statement which-

(a)(1) lists the item or service for which payment has been made and the amount of such payment for each item or service; and

(a)(2) includes a notice of the individual's right to request an itemized statement (as provided in subsection (b)).

(b) Request For Itemized Statement For Medicare Items And Services.-

(b)(1) In General.- An individual may submit a written request to any physician, provider, supplier, or any other person (including an organization, agency, or other entity) for an itemized statement for any item or service provided to such individual by such person with respect to which payment has been made under this title.

(b)(2) 30-Day Period To Furnish Statement.-

(b)(2)(A) In General.-Not later than 30 days after the date on which a request under paragraph (1) has been made, a person described in such paragraph shall furnish an itemized statement describing each item or service provided to the individual requesting the itemized statement.

(b)(2)(B) Penalty.-Whoever knowingly fails to furnish an itemized statement in accordance with subparagraph (A) shall be subject to a civil money penalty of not more than $100 for each such failure. Such penalty shall be imposed and collected in the same manner as civil money penalties under subsection (a) of section 1128A are imposed and collected under that section.

(b)(3) Review Of Itemized Statement.-

(b)(3)(A) In General.-Not later than 90 days after the receipt of an itemized statement furnished under paragraph (1), an individual may submit a written request for a review of the itemized statement to the Secretary.

(b)(3)(B) Specific Allegations.- A request for a review of the itemized statement shall identify-

(b)(3)(B)(i) specific items or services that the individual believes were not provided as claimed, or

(b)(3)(B)(ii) any other billing irregularity (including duplicate billing).

(b)(4) Findings Of Secretary.-The Secretary shall, with respect to each written request submitted under paragraph (3), determine whether the itemized statement identifies specific items or services that were not provided as claimed or any other billing irregularity (including duplicate billing) that has resulted in unnecessary payments under this title.

(b)(5) Recovery Of Amounts.-The Secretary shall take all appropriate measures to recover amounts unnecessarily paid under this title with respect to a statement described in paragraph (4).

¹¹ See Vol. II, P.L. 108-173, §925, with respect to the inclusion of additional information in notices to beneficiaries about skilled nursing faciity benefits.