CMS Pub. 100-08, ch. 3, § 3.2.3.2

A. Prepayment Review Time Frames

When requesting documentation for prepayment review, the MACs and UPICs shall

notify providers when they expect documentation to be received. Per 42 CFR § 405.903,

providers and suppliers have 45 calendar days to submit additional documentation in

response to a MAC, RAC, or SMRC request. Providers and suppliers have 30 calendar

days to respond to a UPIC request.

Contractors may accept documentation received after the 45 and 30-calendar day (for

UPICs) time frames for good cause. Good cause means situations such as natural

disasters, interruptions in business practices, or other extenuating circumstances that the

contractor deems good cause in accepting the documentation. Per 42 CFR § 405.930,

reviewers shall deny claims when the requested documentation to support payment is not

received by the expected time frame.

B. Post-payment Review Time Frames

When requesting documentation for post-payment review, the MACs, CERT, SMRC,

UPICs and RACs shall notify providers when they expect documentation to be received.

Per 42 CFR § 405.929, providers and suppliers have 45 calendar days to submit

additional documentation in response to a MAC, RAC, SMRC or CERT request.

Providers and suppliers have 30 calendar days to respond to a UPIC request. Contractors

may accept documentation received after the 45 and 30-calendar day (for UPICs) time

frames for good cause. Good cause means situations such as natural disasters,

interruptions in business practices, or other extenuating circumstances that the contractor

deems good cause in accepting the documentation.

Per 42 CFR § 405.930, contractors shall deny claims when the requested documentation

to support payment is not received by the expected time frame (including any applicable

extensions).

C. For esMD submissions

The esMD review contractor shall use the esMD Cloud system receipt date as the date the

documentation was received. If the esMD Cloud receipt date is outside of the contractors

normal business hours, the following business day shall be used as the receipt date.

Contractors shall pull for esMD files and latest transaction status at least every 4 hours

(business hours) daily; including a mandatory pulling between the hours of 6-7pm EST

daily. If unforeseeable circumstances occur, in which contractors are not technically

capable of retrieving documentation in a timely manner due to issues outside of their

control, contractors are to notify the esMD Team and can use the date documentation was

available to be retrieved once issues have been resolved in the esMD Cloud system.

D. Kiteworks Submissions

This section applies to the UPICs and the I-MEDIC. When requesting additional

documentation for medical review using Kiteworks, if, after no more than two attempts of

sending the ADR request via Kiteworks (to include atleast 3 calendar days between

attempts for a response), there is no response (i.e., no acknowledgment/download/receipt

email is received from Kiteworks), the request shall be sent via certified mail, FedEx,

UPS, fax etc.