US · guidance
CMS Pub. 100-08, ch. 3, § 3.7
Corrective Actions
This section applies to MACs.
The MACs shall take corrective actions they deem necessary based upon their findings
during or after a review. These actions may include payment suspension, imposition of
civil money penalties, institution of prepayment or postpayment review, additional edits,
etc.
Providers/suppliers who show a pattern of failing to comply with requests for additional
supporting documentation for any claims submitted to CMS may be subject to medical
record review for all claims. This paragraph applies to both providers and suppliers and
to instances in which CMS or its contractors request documentation directly from these
entities to support services billed on the claim. This paragraph does not change or
diminish the provider’s or supplier’s responsibility to provide required documentation.
For purposes of this paragraph, a pattern is two or more ADRs that have gone
unanswered.
History
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
20174cf8e754717a4e55d8e8feb95314634a278291b45fa5b843076e98bb00eb
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