CMS Pub. 100-08, ch. 8, § 8.3

This section applies to Medicare Administrative Contractors (MACs) and Unified

Program Integrity Contractors (UPICs).

Hereinafter, suspension of payment may be referenced as “payment suspension.”

Requests for Suspension of Payment (“Payment Suspension”) may be approved when

there is reliable information that an overpayment exists, when payments to be made may

not be correct, or when there is a credible allegation of fraud existing against a provider.

The process by which the UPIC notifies and coordinates with the MAC to implement a

CMS-approved suspension of payment shall be documented in the Joint Operating

Agreement (JOA) between the MAC and the UPIC. The UPICs shall advise and

coordinate the imposition of a payment suspension with the appropriate MAC when a

payment suspension has been approved by CMS. The UPIC shall perform the necessary

medical review and development of overpayments for payment suspensions that have

received CMS approval, when appropriate.

Medicare authority to withhold payment in whole or in part for claims otherwise

determined to be payable is found in federal regulations at 42 CFR §405.370-375, which

provide for the suspension of payments.

All payment suspensions shall be referred to the CMS/Center for Program Integrity (CPI)

via the Unified Case Management System (UCM) for approval. UPICs shall notify their

appropriate CPI Business Function Lead (BFL), with a copy to the Contracting Officer’s

Representative (COR), of the submission by providing the UCM number via email.