US · guidance
CMS Pub. 100-08, ch. 2, § 2.1
Identifying Potential Errors - Introduction
A. Contractors To Which This Section Applies
This section applies to MACs, UPICs, Recovery Auditors, and Supplemental Medical
Review Contractor (SMRC).
B. General
This chapter specifies resources and procedures to the MACs, UPICs, Recovery Auditors,
and the SMRC. The contractors shall use these instructions to identify and verify
potential errors to produce the greatest protection to the Medicare program. Contractors
should objectively use analytical methodologies to evaluate potential errors and not take
administrative action unless they have verified the error and determined that the error is a
high enough priority to justify the action. They should also archive the error including
supporting rationale for selection. (See Reliable Information in Pub. 100-08, Exhibits,
Exhibit 4.)
C. Review of Data
Data analysis is an essential first step in determining whether patterns of claims
submissions and payments indicate potential problems. Such data analysis should include
identification of statistical outliers in billing patterns within a well-defined group, or
more sophisticated detection of patterns within claims or groups of claims that might
suggest improper billing or payment.
Data analysis shall be undertaken as part of general surveillance and review of submitted
claims, or shall be conducted in response to information about specific problems
stemming from complaints, provider or beneficiary input, fraud alerts, reports from CMS,
other MACs, or independent government and nongovernmental agencies.
History
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
1a1042bf4166e9b7074cf03d266a369b8c89707fc04a50b436e16ed90dd91c06
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