US · guidance
CMS Pub. 100-04, ch. 29, § 280.3
Claims Where There is Evidence That Items or Services Were Not Furnished or
Were Not Furnished as Billed
(Rev. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19)
Where there is a substantial basis for determining that an item or service either was not furnished or was not
furnished as billed, the MAC may deny or down-code payment, as appropriate. The reviewer must ensure
that the case file clearly documents the evidence that formed the basis for the determination. Appeal rights
after such a determination remain the same as they would for any other unfavorable decision. If the MAC
has reason to believe or evidence to support that items or services were not furnished or were not furnished
as billed, it shall send a copy of the decision to its UPIC.
History
(Rev. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
aea6d5699588e222bb743cda9692e4e62e08f98c05b4108bd93fda95879f3e23
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