CMS Pub. 100-08, ch. 4, § 4.2.2.8.1

Unified Program Integrity Contractors and Other Entities

(Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21)

This section applies to UPICs.

The UPIC shall coordinate with UPICs in other jurisdictions, as directed in the USOW

and Task Order Statement of Works (SOWs).

The UPIC shall establish and maintain formal and informal communication with state

survey agencies, the OIG, the DOJ, state Medicaid agency, other Medicare contractors,

other UPICs, and other organizations as applicable to determine information that is

available and that should be exchanged to enhance program integrity activities.

If the UPIC identifies a potential quality problem with a provider or practitioner in its

area, it shall refer such cases to the appropriate entity, be it the QIO, state medical board,

state licensing agency, etc. Any provider-specific information shall be handled as

confidential information.

4.2.2.8.1.1 - Coordination with the Office of Inspector General

(Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23)

The UPICs shall establish regular (i.e., monthly or quarterly) teleconference meetings

with Regional LE from OIG and CMS for the purpose of discussing:

• the status of referrals and immediate advisements;

• any relevant updates to previously discussed cases (i.e., contractor

identified spikes in billing, change to the operational status of a provider,

patient harm situations, etc.);

• data analysis projects (i.e., planned data projects, results of recently

completed data projects, etc.); and

• areas of interest to CMS, OIG, or other regional partners.

Other agenda topics may include a discussion regarding areas of concern in the UPIC

and/or Regional LE respective region, case/project developments (including planned

provider onsite reviews to ensure the proposed activities do not negatively affect any

ongoing LE efforts), and other topics. In preparation for the meeting, the UPIC shall set

the agenda and prepare any additional documents or reports for the participants at least

three (3) business days prior to the meeting.

However, at no time shall a referral be made as a result of discussions during these

regular meetings. If OIG expresses interest, the contractor shall discuss the case with the

BFL, with a copy to the COR, to determine if it should be added to the next case

coordination meeting with CMS.

4.2.2.8.1.2 - Joint Operating Agreement

(Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21)

This section applies to UPICs, SMRCs, MACs, RACs, and QICs, as indicated.

A JOA is a document developed between two entities (CMS contractors) that delineates

the roles and responsibilities of each entity regarding their interactions with each other

on CMS contracts.

The UPICs shall have JOAs with the entities as outlined in their Statement of Work. As

it applies to the UPIC’s task orders, the JOA with the MACs shall, at a minimum,

provide information on assigned responsibilities, timeframes, processes and procedures,

and coordination. Additional detail related to this information is referenced in the UPIC

Statement of Work.

Periodically, there are instances in which the UPIC is in need of the requested

information in a shorter timeframe than 30 calendar days. To account for these instances,

the UPICs and MACs may add language to their JOA that allows for a shorter timeframe

for the MAC to furnish the requested information (i.e. 48 hours, 72, hours, etc.).

4.2.2.8.1.3– MAC and UPIC Coordination on Voluntary Refunds

(Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21)

This section applies to UPICs and MACs, as indicated.

Voluntary refund checks payable to the Medicare program shall not be returned to the

provider/supplier, regardless of the amount of the refund. The UPIC shall communicate

with the MAC staff responsible for processing voluntary refunds to obtain information

on the checks received. The MAC shall refer to Pub. 100-06, Financial Management

Manual, for instructions on processing and reporting unsolicited/voluntary refunds

received from providers/physicians/suppliers.

The UPIC shall perform an investigation on any voluntary refund where there is

suspicion of inappropriate payment or if a provider/supplier is under an active

investigation.

Should the UPIC receive a voluntary refund check in error, the UPIC shall coordinate

the transfer of voluntary refund checks to the MAC through the JOA.

Through the JOA, the UPIC shall establish a mechanism whereby the MAC notifies the

UPIC on a regular basis of all voluntary refunds it received. The UPIC or MAC shall

send one letter annually (calendar year) to any provider/supplier that submits a voluntary

refund during that calendar year, advising the provider/supplier of the following:

“The acceptance of a voluntary refund in no way affects or limits the rights of the

Federal Government or any of its agencies or agents to pursue any appropriate criminal,

civil, or administrative remedies arising from or relating to these or any other claims.”

The UPIC and MAC shall establish in the JOA which contractor sends the above

language. The MACs may send the language above on a voluntary refund

acknowledgement letter or on a Remittance Advice, if this capability exists.

The UPIC shall refer to section 4.8 of this chapter for law enforcement requests for

voluntary refund information.

4.2.2.8.1.4 – Contractor Coordination and Suppression and Exclusion

Upload Requirements Related to the RAC Data Warehouse

(Rev. 13485; Issued: 12-23-25; Effective: 01-26-26; Implementation: 01-26-26)

This section applies to all medical review contractors (UPIC, RAC, MAC, CERT,

SMRC) uploading suppression and exclusions into the RACDW unless otherwise noted.

The CMS utilizes the RAC Data Warehouse (RACDW) to track review contractor

activity. The RACDW allows contractors that perform medical reviews to prevent

duplicative claim reviews by using the Suppressions and Exclusions process.

For assistance with file errors, contact the system administrators at

helpdesk.RACDW@koniag-gs.com. Current suppression/exclusion file layouts are

available by download from the RACDW itself.

Suppressions:

Suppressions are used by Non-RAC entities to identify a set of claims as temporarily

off-limits for selection by other review entities. The set of claims are identified by using

the current suppression file layout, which utilizes parameters to narrow the universe of

suppressed claims.

Suppression Requirements:

Suppressions shall be entered using the most current suppression file layout found in the

RACDW. All required fields shall be submitted upon initial upload. The Suppression file

layout does not allow the suppression of claims with a paid date older than 3 years.

Individual NPIs or legacy numbers shall be entered for each suppression. If a provider

has multiple NPIs or legacy numbers, the RACDW will only suppress uploaded NPIs or

legacy numbers. Any error codes generated from the system shall be corrected by the

uploading entity before successful upload can be completed. Unless other parameters

have been included on the initial upload, all suppressions will automatically expire

within 12 months of the date they were entered into the RACDW. If a suppression is

required for longer than 12 months, the contractor shall re-new the suppression prior to

the expiration date. The individual user that uploaded a suppression file shall be

responsible for releasing any suppressions in that file that are no longer valid within 2

business days. Data entered in the situational fields in the suppression file layout shall

require an additional narrative in the comments field for final approval. The contractor

shall be responsible for correcting and re-uploading any disapproved suppressions within

2 business days of the disapproval.

Exclusions:

Exclusions are claims that have been previously reviewed by a medical review entity (or

that are part of an extrapolated settlement universe). They are identified by specific

claim number uploaded into the RACDW utilizing the current exclusion file layout and

are permanently flagged as unavailable for additional review by a review contractor.

Exclusion Requirements:

Exclusions shall be entered using the most current version of the exclusion file layout

found in the RACDW. All required fields shall be submitted upon initial upload. Any

error codes generated from the system shall be corrected before successful upload can be

completed.

UPIC-Specific Requirements for Suppressions and Exclusions:

The UPIC shall enter suppressions in the RACDW as soon as the investigation begins,

no later than 2 business days after the investigation is opened. UPICs can renew any

active suppressions that are within 30 days of their expiration date. To do so, the UPIC

shall provide a new date, add ‘Renewal’ in the justification space, and resubmit the entry

for approval in the RACDW. The UPIC shall release suppressions within 2 business

days of the underlying investigations/cases being closed.

Statistically Valid Random Sampling (SVRS):

In the event that the UPIC is unable to determine at the time of review whether any

overpayments that are identified will be extrapolated to the parent claim universe, the

UPIC shall enter a suppression utilizing the current file layout. If the UPIC does

ultimately assess an extrapolated overpayment, the UPIC shall release the suppression

and exclude the entire universe. If the overpayment is computed based only on the

sampled claims (i.e., the overpayment is not projected to the entire universe), the UPIC

shall release the suppression and exclude only the sample claims that were actually

reviewed.

If a provider is under review by another contractor (RAC, MAC, CERT, SMRC), the

UPIC shall contact that contractor to determine which entity should continue to review

that provider and how to proceed with the current medical review, such as closing it out

or completing the medical review and then referring it to the UPIC.