CMS Pub. 100-06, ch. 7, § 30.9.5

I – Control

Objective

Number

I – CUEC Description

I.1 CMS ensures that applicable CMS systems are appropriately

updated.

I.2 CMS provides information to the contractor regarding new

providers, change of ownership for an existing provider, termination

of a provider, or a change of Medicare Administrative Contractor

(MAC) to ensure the information is processed in System Tracking

for Audit and Reimbursement (STAR) in a timely and accurate

manner and reflected in subsequent audit activities.

I – Control

Objective

Number

I – CUEC Description

1.3 CMS provides general instructions to ensure that Provider Cost

Reports are properly submitted and accepted. Appropriate program

policies and instructions are provided to address situations where

the provider did not file a cost report.

I.4 CMS provides Uniform Desk Review thresholds for determination

of limited and full reviews.

I.5 CMS provides general instructions to ensure that Provider Cost

Reports are issued a Notice of Program Reimbursement timely.

I.6 CMS provides general instructions to ensure audit systems (STAR)

are updated in compliance with program instructions.

I.7 CMS regulations and program policy are provided to ensure that the

contractor’s cost report re-opening process is in compliance.

I.8 CMS regulations, program policy, and Provider Reimbursement

Review Board (PRRB) rules are provided to ensure that the

contractor’s appeals process is in compliance.

I.9 Control number I.9 reserved. Control not in use as of IOM revision

number 278.

I.10 CMS provides general instructions for audit work that allows for an

internal quality control process to be established.

I.11 CMS provides guidelines and instructions to ensure that cost reports

are scoped and selected for audit or settled without audit and that

audit plans are approved by CMS and in compliance.

I.12 CMS provides manual instructions and timelines to ensure that the

contractor’s audit process is conducted in compliance, i.e.,

timeframes for issuance of the engagement letter, documentation

requests, pre-exit and exit conferences, and settlement of the audited

cost report.

I.13 CMS provides instructions for audit programs, desk review

programs and CMS audit and reimbursement policies, and other

audit related instructions so that they can be communicated to audit

staff.

I.14 CMS provides instructions to ensure the contractor’s audit staff

maintains its necessary knowledge and skills by completing

continuing education and training (CET).

I – Control

Objective

Number

I – CUEC Description

I.15 Supervisory reviews of the audit and settlement process are

conducted and the policies and procedures for these reviews are

communicated to all supervisors in accordance with CMS program

instructions.

I.16 All cost reports where fraud and abuse is suspected shall be referred

to the Unified Program Integrity Contractor (UPIC) in accordance

with CMS and contractor instructions.

I.17 The contractor has processes and procedures in place to document

that supervisory reviews by provider audit department management

were completed on all provider audit Corrective Action Plans

(CAPs) from the establishment of the CAPs to the implementation

and validation of the CAPs.

I.18 HITECH incentive payments for Medicare subsection (d) and critical

access hospitals are calculated properly, in accordance with CMS’

regulations, policies, and instructions. Data is properly entered into the

FISS screens in order for the HITECH system to generate the incentive

payments.

I.19 CMS provides instructions and guidelines to ensure that cap

determination letters are issued accurately and timely to Hospices and

include all related documentation.

I.1, I.2, I.3, and

I.6

CMS provides a database, System Tracking for Audit and

Reimbursement, so that information is accurate and timely. CMS

maintains and updates program instructions to ensure that inputs

into the STAR system are in compliance.

End Section 30.9.5 – I CUECs – Provider Audit: Back to Table of Contents