Proof of Payment

100.3.1 - Proof of Payment (Rev. 1, 10-01-03) The following types of documentation are sufficient to establish that payment was made in the amount alleged: • An itemized bill from the provider, practitioner, or supplier reflecting the items and services for which the provider, practitioner, or supplier has been found liable and has received payment along with the payer’s cancelled check, money order receipt, or statement of receipt from the provider, physician, or supplier; • A summary bill from the provider, practitioner, or supplier which pertains to the items and services for which the provider, practitioner, or supplier has been found liable and has collected from the beneficiary or other person along with the payer’s cancelled check, money order receipt, or a statement of receipt from the provider, practitioner, or supplier showing the same total amount; • The payer’s cancelled check, money order receipt, or the statement of receipt from the provider, practitioner, or supplier if the contractor’s records reflect the provider, practitioner, or supplier’s charges for the items and services for which the provider, practitioner, or supplier has been found liable and these equal the total of the amount paid; or • If the requester alleges that the provider, practitioner, or supplier did not furnish an itemized bill or a receipted statement and no other proof of payment is available, the contractor obtains a statement on Form SSA-795 to this effect from all parties involved, including the provider, physician, or supplier if possible. The statement should describe the circumstances, such as the manner of payment, and the reasons for not obtaining a receipt or any proof of payment. If there were any witnesses to the payment, the contractor obtains their statements on Form SSA-795. The contractor refers any questions as to the acceptability of proof of payment to the RO. When the beneficiary or other person on behalf of the beneficiary initially contacts the SSO, that office sends the statements and evidence relevant to the indemnification claim to the appropriate contractor. If future contact with the beneficiary or other person is necessary, the contractor proceeds with a direct contact unless the assistance of the SSO is needed.