US · guidance
CMS Pub. 100-08, ch. 3, § 3.3.2
Medical Review Guidance
This section applies to MACs, CERT, Recovery Auditors, and UPICs, as
indicated.
This section describes the requirements that MACs, CERT, Recovery Auditors, and
UPICs shall follow when reviewing submitted documentation. Additional requirements
for UPICs are located in PIM chapter 4. When UPIC staff is performing benefit integrity
reviews, their focus is different than that of MACs, CERT, and Recovery Auditors. For
example, UPIC staff looks for some of the following situations when reviewing
documentation:
• Possible falsification or other evidence of alterations including, but
not limited to: obliterated sections; missing pages, inserted pages,
white out; and excessive late entries;
• Evidence that the service billed for was actually provided; or,
• Patterns and trends that may indicate potential fraud.
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
679f1138d509e427a1afc8ca7f37ab38aa6f1fb4091043653b493270fc5f3bbe
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