Suggested Templates for Compliance with Certain Supplier Standards

The attached model forms were created in an effort to educate suppliers regarding certain supplier standards listed in 42 CFR.424.57(c).

Please note that these forms are simply templates and suppliers should feel free to create their own forms. Suppliers using their own forms must ensure the forms are capturing and documenting information as required by the supplier standards.

The 'Model Warranty Information Form' addresses supplier standard #6, which requires the supplier to inform Medicare beneficiaries about the warranty coverage of any piece of equipment or any supply provided. The text of the standard reads as follows:

  • A supplier honors all warranties expressed and implied under applicable State law. A supplier must not charge the beneficiary or the Medicare program for the repair or replacement of Medicare covered items or for services covered under warranty. This standard applies to all purchased and rented items, including capped rental items, as described in Sec. 414.229 of this subchapter. The supplier must provide, upon request, documentation that it has provided beneficiaries with information about Medicare covered items covered under warranty, in the form of copies of letters, logs or signed notices.

The 'Model Complaint Resolution Protocol' form addresses standard #19, which requires the supplier to have a protocol in place to resolve complaints received from Medicare beneficiaries regarding services rendered. The text of the standard reads as follows:

  • A supplier must have a complaint resolution protocol to address beneficiary complaints that relate to supplier standards in paragraph (c) of this section and keep written complaints, related correspondence and any notes of actions taken in response to written and oral complaints. Failure to maintain such information may be considered evidence that supplier standards have not been met. (This information must be kept at its physical facility and made available to CMS upon request.)

The 'Model Complaint Log Sheet' addresses standard #20, which requires the supplier to log certain specific information about complaints received from Medicare beneficiaries. The text of the standard reads as follows:

  • A supplier must maintain the following information on all written and oral beneficiary complaints, including telephone complaints, it receives:

    (i) The name, address, telephone number, and health insurance claim number of the beneficiary.
    (ii) A summary of the complaint; the date it was received; the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint.
    (iii) If an investigation was not conducted, the name of the person making the decision and the reason for the decision.

The final form addresses supplier standard #5, which requires suppliers to advise beneficiaries of the rent/purchase option for capped and inexpensive or routinely purchased items. The text of the standard reads as follows:

  • Advises beneficiaries that they may either rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental durable medical equipment, as defined in Sec. 414.220(a) of this subchapter. (The supplier must provide, upon request, documentation that it has provided beneficiaries with this information, in the form of copies of letters, logs, or signed notices).

Should you have any questions or comments about these forms, please feel free to contact the NSC at (866) 238-9652. To access or download each of the model forms, open the links below.

Contact NSC

Email National Supplier Clearinghouse

Contact a specific NSC department

Telephone: 866-238-9652

IVR: 866-238-9652

Address:

National Supplier Clearinghouse

Palmetto GBA, AG-495

P.O. Box 100142

Columbia, SC 29202-3142

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 


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Model Complaint Log Sheet.PDF
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Model Complaint Resolution Protocol.PDF
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model warranty information form.pdf
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Capped Rental - Inexpensive or Routinely Purchased Items Notification.pdf