US · guidance
CMS Pub. 100-04, ch. 29, § 280.4
Responsibilities of Adjudicators
If, during the course of the redetermination, the reviewer suspects a civil or criminal law violation, the
reviewer shall render a decision only on the coverage or payment issues raised by the redetermination
request. Although the reviewer cannot make a determination of civil or criminal fraud, he/she may still deny
or reduce payment if he/she believes that the items or services at issue were not rendered, or were not
rendered as billed (as discussed above). In making this determination, the reviewer may consider all
available evidence that is included in the case file, including witness testimony, medical records, and
evidence compiled through a fraud investigation, as discussed above. (See §310.4.B below.) In addition to
denying the claims because the services were not rendered as billed, if the reviewer suspects fraud, he/she
shall forward information regarding the potential civil or criminal violation to the UPIC. For further
discussion on Medicare fraud issues, refer to the Medicare Program Integrity Manual, IOM 100-08, Chapter
4.
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
ecac86f55e401427c7bf9ba3b4eccf93210da74ff10bd5d0814a1ef87e1aed6f
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