Development and Documentation of Indemnification Requests

100.3 - Development and Documentation of Indemnification Requests (Rev. 1186, Issued: 02-23-07; Effective: 01-01-06; Implementation: 05-23-07) When the contractor receives a request or inquiry concerning indemnification directly from the beneficiary or the beneficiary’s authorized representative, it must obtain the following information and documentation: • Identifying information sufficient for the contractor to locate the claim(s) for noncovered items or services for which payment has been made to the provider, practitioner, or supplier by the beneficiary or other person and for which the liability of the beneficiary was limited. Ordinarily, the initial MSN or appeal determination suffices. • A statement on Form SSA-795, “Statement of Claimant or Other Person,” (see §100.10, Exhibit 4 ) to the effect that the requester paid the provider, practitioner, or supplier all or some of the charges for the noncovered items or services for which the beneficiary’s liability was limited. The statement must specify the amount the requester has paid the provider, practitioner, or supplier. If the requester submits this information in a letter, the letter serves as the signed statement.