US · guidance
CMS Pub. 100-08, ch. 8, § 8.3.1.2
Reliable Information that an Overpayment Exists - General
Suspensions
(Rev. 13762; Issued: 05-27-26; Effective: 06-29-26; Implementation: 06-29-26)
A payment suspension may be implemented when the MAC, UPIC, or CMS possesses
reliable information that an overpayment exists. In this situation, the MAC shall refer its
information to the respective UPIC for development of a potential suspension. If
warranted, the UPIC shall complete the payment suspension AAR and submit the
payment suspension recommendation via the UCM. The AAR shall serve as the UPIC’s
documented recommendation for CMS’ consideration of a payment suspension and,
when completed, include the UPIC’s findings and all pertinent provider/supplier
information. The AAR, draft notice of suspension, and all other relevant documentation
that supports the suspension recommendation shall be uploaded by the contractor as part
of the UCM submission. For the purposes of this section, these types of payment
suspensions will be called “general suspensions.”
EXAMPLE (including but not limited to): Several claimed services identified from
either a prepayment or post-payment review were determined to be non-covered or
miscoded. It has been determined that there is a pattern of noncompliant billings (the
provider has billed this service many times before) and it is suspected that there may be a
substantial number of additional non-covered or miscoded claims paid in the past.
History
(Rev. 13762; Issued: 05-27-26; Effective: 06-29-26; Implementation: 06-29-26)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
70455f04332015ea86c194b947f788592efa8a3b0ad7b44209d0a7ade3ad8a53
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.