CMS Pub. 100-08, ch. 3, § 3.2.2.1

This section applies to MAC.

A. Provider Tracking System (PTS)

The MACs shall have a PTS in place to identify and track all individual providers

currently under action plans to correct identified problems, such, as not reasonable and

necessary, incorrect coding, and inappropriate billing. MACs shall use the PTS to

coordinate contacts with providers such as MR notifications, telephone calls directly

related to probe reviews, and referrals to POE. The MACs shall ensure that if a provider

is to be contacted as a result of more than one problem, redundant contacts are

minimized. The MACs shall also coordinate corrective action information with the

UPICs to ensure contacts are not in conflict with benefit integrity related activities. The

MAC PTS shall contain the date a provider is put on a provider- specific edit. The MAC

shall reassess all providers on provider-specific prepayment or post-payment review on a

quarterly basis to determine whether the behavior has improved. The MAC shall note the

results of these quarterly assessments in the PTS. If the behavior has improved

sufficiently and the edit was turned off, note that date as well in the PTS. When a MAC

becomes aware that the provider has appealed a medical review determination to an

Administrative Law Judge (ALJ), the MAC should send a letter to the ALJ and describe

the information in the PTS to demonstrate the corrective actions that have been taken by

the MAC.

B. RAC Case Files

The RAC shall maintain case files following the guidelines in the RAC SOW.

C. Provider Addresses

This section applies to MACs, CERT, and RACs, as indicated.

The MACs, CERT, SMRC, and RACs shall mail the ADR to the best-known address for

the provider. MACs are encouraged to indicate the procedure a provider can follow to

update address information in their ADRs and on their websites. If a provider wishes to

have ADRs sent to one address but demand letters sent to a different address, MACs are

encouraged to accommodate this request.

Note: Providers and suppliers must complete and submit a Medicare enrollment

application (either the paper CMS-855 or a submission via Internet-based Provider

Enrollment, Chain & Ownership [PECOS] to change existing information in the

Medicare enrollment record.)

D. When the Provider or Supplier No Longer Occupies a Physical

Address

This section applies to MACs, RACs, SMRC, and UPICs, as indicated.

When the MACs, RACs, SMRC, and UPICs become aware that the provider or supplier

no longer occupies a physical address, any future correspondence shall reference only the

claim control numbers and not list the individual beneficiary data (e.g., names and

Medicare beneficiary identifiers). This process is contingent on current automated system

limits.

The following are situations where the Contractors can assume the provider or supplier

no longer occupies the last known location. This list is not exhaustive and the Contractors

should use other means to confirm addresses, at their discretion.

• The Contractors receive mail that has been returned by the post

office indicating no known address;

• An onsite visit has confirmed the address is vacant or is occupied

by another occupant; or,

• A beneficiary complaint(s) is on record stating the provider or

supplier is no longer at the address and follow up confirms the

complaint.

In the above situations, correspondence from the Contractors shall only contain the claim

control number and advise the provider or supplier to contact them for a list of the

specific claims associated with the overpayment. This process will prevent the potential

compromise of Medicare beneficiary names and/or Medicare beneficiary identifiers being

sent to an abandoned address (or a location with a new occupant). If the letter is returned

from the post office, maintain the notification on file for evidence.