US · guidance
CMS Pub. 100-08, ch. 8, § 8.3.1.4
Provider Fails to Furnish Records and Other Requested
Information - General Suspensions
(Rev. 13762; Issued: 05-27-26; Effective: 06-29-26; Implementation: 06-29-26)
A payment suspension may be used when the MAC, UPIC, or CMS possesses reliable
information that the provider has failed to furnish records and other information
requested or that is due, and which is needed to determine the amounts due the provider.
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): During a post-payment review, medical
records and other supporting documentation are solicited from the provider to support
payment. The provider fails to submit the requested records after two attempts. The UPIC
may request a payment suspension due to non-response from the provider.
In lieu of imposing a payment suspension, the MAC or UPIC may deny the paid claims
because the provider failed to provide the requested documentation after two attempts. In
either case, the MAC or UPIC should determine if the provider is continuing to submit
claims for the services in question and take appropriate action(s) to correct the behavior.
NOTE: In the above example, if the only reason for the payment suspension is the failure
by the provider to furnish the requested records, and if the provider does eventually
provide the requested information, the UPIC shall discuss this matter with CPI for
guidance.
EXAMPLE (including but not limited to): The provider fails to timely file an
acceptable cost report. Refer to 42 CFR §405.371(d). (NOTE: Such requests regarding
the timely filing of an acceptable cost report shall be submitted only to and approved by
the CMS, Office of Financial Management and not CPI.)
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
17ffea995ae49314570ffe36eaa093ae2a61f524c4c328c4a070cbb19a9c7f33
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