US · guidance
CMS Pub. 100-08, ch. 3, § 3.3.2.3
Mandatory Policy Provisions
This section applies to MACs, RACs, SMRC, CERT and UPICs, as
indicated.
CERT contractors select claims for review on a random basis and do not select claims
that are suspect. The CERT reviewers shall review every line on the randomly selected
claim that affects payment to determine if the following types of requirements are met:
• Coding requirements;
• Benefit category requirements;
• The reasonable and necessary requirements of the NCDs and
LCDs, among others.
The MACs, RACs, SMRC, and UPICs select claims to prevent or identify an improper
payment. They are only required to review the suspect line and not every line on the
selected claims. Along with reviewing the line for coding accuracy, the MACs should
review for medical necessity if the provider has been notified that both types of review
will occur. The RACs shall review the claim line(s) identified, as per the CMS-approved
review guidelines, as indicated to the provider in the ADR letter, and in accordance with
their SOW. The UPICs shall use discretion in notifying the provider.
History
(Rev. 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
02f7300a2d63cbce2d2a9a3bc67b9c4935497eb276c16d7562424379ce9998f0
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