Worksheets

8.4.4.4.3 - Worksheets (Rev. 906; Issued: 09-26-19; Effective: 01-02-19; Implementation: 01-02-19) The contractor shall maintain any formal worksheets used by reviewers. The worksheets may include, but are not limited to data and information, such as: • Name and identification number of the provider or supplier; • Name and title of reviewer; • The HICN/MBI, the unique claim identifier (e.g., the claim control number), and the line item identifier; • Identification of each sampling unit and its components (e.g., UB-92 or attached medical information); • Stratum and cluster identifiers, if applicable; • The amount of the original submitted charges (in column format); • Other information required by cost report worksheets in Pub. 100-08, Exhibits 9 through 12; • The amount paid; • The amount that should have been paid (either over or underpaid amount); and • The date(s) of service.