CMS Pub. 100-08, ch. 4, § 4.1

The CMS Pub. 100-08, Program Integrity Manual (PIM), reflects the principles, values,

and priorities of the Medicare Integrity Program (MIP). The primary principle of

program integrity (PI) is to pay claims correctly. To meet this goal, Unified Program

Integrity Contractors (UPICs), Investigations Medicare Drug Integrity Contractor (I-MEDIC), Supplemental Medical Review Contractors (SMRC) and Medicare

Administrative Contractors (MACs) must ensure that Medicare pays the right amount

for covered and correctly coded services rendered to eligible beneficiaries by legitimate

providers. The focus of the UPICs, SMRCs and MACs shall be to ensure compliance

with Medicare regulations, refer suspected fraud and abuse to our Law Enforcement

(LE) partners, and/or recommend revocation of providers that are non-compliant with

Medicare regulation and policies. The Centers for Medicare & Medicaid Services (CMS)

follows four parallel strategies in meeting this goal:

1. Prevent fraud through effective enrollment and education of

providers/suppliers and beneficiaries;

2. Encourage early detection (through, for example, the Fraud Prevention

System (FPS), medical review (MR) and data analysis);

3. Coordinate closely with partners, including other UPICs, SMRCs, MACs, LE

agencies, and State PI units; and

4. Enact fair and firm enforcement policies.

The UPICs shall coordinate with their Contracting Officer’s Representative(s) (COR)

and their Business Function Lead(s) (BFL) to fulfill all direction as described in the

PIM. For all guidance and instruction described in this chapter, the UPIC shall directly

contact the appropriate UPIC BFL, with a copy to the UPIC COR, for any Technical

issues and/or questions (i.e. process related issues/inquiries, workload prioritization,

etc.). Additionally, the UPIC shall directly contact the UPIC COR, with a copy to the

appropriate UPIC BFL, for any Business issues and/or questions (i.e., level of effort

concerns, funding issues, etc.).

The UPICs shall follow the PIM to the extent outlined in their respective task orders’

Statement of Work (SOW). The UPICs shall only perform the functions outlined in the

PIM as they pertain to their own operation. The UPICs, in partnership with CMS, shall

be proactive and innovative in finding ways to enhance the performance of PIM

guidelines.

For this entire chapter, any reference to UPICs shall also apply to the I-MEDIC, unless

otherwise noted or identified in the Contractors’ SOW. MACs shall follow the PIM in

accordance with their SOW.

To facilitate understanding, the terms used in the PIM are defined in PIM Exhibit 1. The

acronyms used in the PIM are listed in PIM Exhibit 23.