US · guidance
CMS Pub. 100-08, ch. 8, § 8.3.1.3
Reliable Information that the Payments to Be Made May Not
Be Correct - 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 or UPIC or CMS possesses
reliable information that the payments to be made may not be correct. 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 a
post-payment review were determined to be non-covered or miscoded. It has been
determined that the provider has not changed its billing behavior and it is suspected that
there may be a continuance of non-covered or miscoded claimed services to be billed in
the future.
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
d0d9dcad29a98f942ed30e42bc0dcbd6b43c7b7c39474e9062da7df950389305
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