Form 12 SIRS Individual Interaction-Complex Form

OMB Control Number: 0985-0040 Expiration: Month/Day/2023

INDIVIDUAL INTERACTION: COMPLEX INTERACTION FORM
* Items marked with asterisk (*) indicate required fields
Type of Interaction*:

Individual Interaction

Session Conducted By*:
Date of Interaction (MM/DD/YYYY)*:

Title of Interaction:

Time Spent in Minutes*:

End Date (if applicable):
Zip code*:

State*:

Reference Number: Auto-Populated

County:

Organization: Auto-Populated

Notes:

Beneficiary Name and Contact Information
Beneficiary First Name:
Beneficiary Last Name:

Beneficiary Phone: (

Beneficiary Address:

)-

Beneficiary City:

-

Beneficiary State:

Beneficiary Email:

Beneficiary Zip Code:
Beneficiary Demographic Information
 American Indian or Alaskan Native
Race
 Asian
(Multiple selections
 Black or African American
allowed):
 Hispanic
Latino
 or Female
Gender (Select only one):
 Male
Date of Birth (MM/DD/YYYY):



Native Hawaiian or Other
Pacific Islander
 White
 Not Collected
Other



Not Collected



Medicare Number:
Medicaid Number:
Other Information:

Permission to Contact Beneficiary?


Yes


No

Topic(s) Discussed:
 Conditional Payments
 Consumer Protection
 Durable Medical Equipment (DME)
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

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Medicare Summary Notice
Medigap or Supplemental Insurance
Opioid Fraud and Abuse
SMP Program Information
SMP Volunteer Recruitment
Social Security
TRICARE




Veteran’s Health Benefits (VA)
Other



Employer Health Plan
General Fraud, Errors, and Abuse
Genetic/DNA Testing
Home Health Care
Hospice
Medicaid
Medical Identity Theft






Medicare Advantage
Medicare Card

Medicare Part A and B
Medicare Part D

Other Topics Discussed Details:
Additional Information
Issue(s):
 Beneficiary Perpetrated Fraud
 Billing Error
 Billing for Services Different From
Received
 Billing for Services Not Provided
 Compromised Medicare Number
 Compromised Social Security Number

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Double Billing
Enrollment / Disenrollment Issues
Kickbacks
Marketing Fraud
Quality of Care Issues
Scams
Other Fraud, Error, or Abuse

Other Fraud, Error, or Abuse Details:
Is the Complainant different from the Beneficiary?


Yes
 No

Complainant Name and Contact Information
Complainant Address:

Complainant First Name:
Complainant Last Name:
Complainant Phone: (

)-

-

Complainant Email:

Complainant
Complainant State:
Complainant Zip Code:

Spouse
Family Member/Caregiver
 Health Care Provider
 Other

Yes


Complainant Relationship to
Beneficiary:
Permission to contact Complainant:



 No

City:

Recoveries Information
Cost Avoidance on behalf of Medicare, Me dicaid, Beneficiaries, or others (xxxx.xx) :
Expected Medicare Recoveries (xxxx.xx):
Additional Expected Medicare Recoveries (xxxx.xx) :
Expected Medicaid Recoveries (xxxx.xx) :
Additional Expected Medicaid Recoveries (xxxx.xx) :
Actual Savings to Beneficiaries (xxxx.xx) :
Other Savings (xxxx.xx):
Explanation:

SMP Action(s):











SMP contacted 1-800-Medicare
SMP contacted CMS Liaison
SMP contacted CMS Regional Office
SMP contacted Federal Trade Commission
SMP contacted Medicare Advantage Plan or
Part D Plan
SMP contacted Medicare PSC or MEDIC
Contractor
SMP contacted MFCU or Medicaid Office
SMP contacted OIG
SMP contacted Other CMS Contractor
SMP contacted Provider/Practitioner







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

SMP contacted Quality Improvement
Organization (QIO)
SMP contacted Secondary Insurer/Plan
SMP contacted SHIP
SMP contacted SMP Resource Center
SMP contacted State Insurance Department
SMP contacted UPIC
SMP sent Release of Information Form and
Request Documents
SMP reviewed Guidelines, Policies, or
Procedures
Other SMP Action

Other SMP Action Details:
Referred Beneficiary to Action(s):






Appeal

Referred beneficiary to 1-800-Medicare
Referred beneficiary to an Ombudsman
Referred beneficiary to contact Medicare
Advantage Plan or Part D Plan
Referred beneficiary to contact MFCU or
Medicaid Office
Referred beneficiary to contact
Provider/Practitioner

Yes
 No

Attach File 1
Attach File 2
Attach File 3
Attach File 4
Attach File 5






Referred beneficiary to contact Quality
Improvement Organization (QIO)
Referred beneficiary to contact Secondary
Insurer/Plan
Referred beneficiary to Federal Trade
Commission
Referred beneficiary to SHIP

Case Notes:


Yes

Refer to OIG Hotline via ACL:



Date Submitted to ACL:
Date ACL Submitted to OIG (MM/DD/YYY):

No

Auto-Populated after saving

ACL Comments:
SMP Representative Name and Contact Information
SMP Representative Name:

SMP Representative Phone Number:
(

SMP Representative Mailing Address:

)-

-

SMP Representative Fax Number:
(

)-

-

SMP Representative Email Address:

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Status of Interaction:

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

Date of Last Status Update
(MM/DD/YYYY):

Open – Research in progress by SMP, less than one year
Open – Awaiting Response to Referral
Closed – Reviewed Internally, no issue identified
Closed – Resolved by SMP
Closed – Referral No Action Required
Closed – Action Taken By Referent
Closed – Handled by SHIP
Closed – Other
Suspended

Subject Name and Contact Information
Organization Name:

Subject Address:

Subject First Name:

Subject City:

Subject Last Name:
Subject State:
Subject Phone: (

)-

-

Subject Zip Code:

Provider Number:
Subject Email:
Subject Website:
Subject Other Information:

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
such collection displays a valid OMB control number (OMB 0985-0040). Public reporting burden for this collection of
information averages 5 minutes per response, including time for gathering, maintaining, completing and reviewing the
collection of information. The obligation to respond to this collection is required to retain or maintain benefits under the
statutory authority from Section 4360(f) of the OBRA.