CMS Pub. 100-08, ch. 4, § 4.10.2.3

The UPIC shall include in the sanction recommendation (to the extent appropriate) the

following information:

• Identification of the subject, including the subject's name, address, date of birth,

social security number, and a brief description of the subject's special field of

medicine. If the subject is an institution or corporation, include a brief description

of the type of services it provides and the names of its officers and directors.

• A brief description of how the violation was discovered.

• A description of the subject's fraudulent or abusive practices and the type of

health service(s) involved.

• A case-by-case written evaluation of the care provided, prepared by the UPIC’s,

or MAC’s MR staff, which includes the patient's medical records. This

evaluation shall cite what care was provided and why such care was unnecessary

and/or of poor quality. (The reviewer may want to consult with someone from

their RO CCSQ.) Medicare reimbursement rules shall not be the basis for a

determination that the care was not medically necessary. The reviewer shall

identify the specific date, place, circumstance, and any other relevant

information. If possible, the reviewer should review the medical records of the

care provided to the patient before and after the care being questioned.

NOTE: A minimum of 10 examples shall be submitted in support of a sanction

recommendation under §1128(b)(6)(B). In addition, none of the services being used to

support the sanction recommendations shall be over 2 years old.

• Documentation supporting the case referral, e.g., records reviewed, copies of any

letters or reports of contact showing efforts to educate the provider, profiles of

the provider who is being recommended for sanction, and relevant information

provided by other program administrative entities.

• Copies of written correspondence and written summaries of the meetings held

with the provider regarding the violation.

• Copies of all notices to the party.

• Information on the amount billed and paid to the provider for the 2 years prior to

the referral.

• Data on program monies on an assigned/non-assigned basis for the last 2 years, if

available.

• Any additional information that may be of value in supporting the proposal to

exclude or that would support the action in the event of a hearing.

NOTE: All documents and medical records should be legible.