CMS Pub. 100-08, ch. 8, § 8.3.2.1

If the UPIC believes that a UPIC-initiated Payment Suspension is a viable option for an

investigation, they shall update UCM appropriately to ensure the case is included on the

next case coordination meeting agenda for discussion. For national or multi-regional

suspensions, only the lead UPIC shall discuss the suspension at the case coordination

meeting.

During the case coordination meeting, if CMS agrees that the criteria for Payment

Suspension is met, CMS will instruct the UPIC to submit the Payment Suspension

recommendation(s) with the completed AAR form to CPI through the UCM. The

Payment Suspension team member will review the submissions and make a formal

determination as to whether a Payment Suspension is a viable option.

During the case coordination meeting, the UPIC may receive additional guidance from

CMS related to subsequent actions related to these investigations. If the UPIC has

questions following the case coordination meeting, the UPIC shall coordinate with its

COR, BFL, and/or suspension team member, as needed.

When a payment suspension is approved by CPI, the UPIC shall inform the respective

MAC of this action and the MAC shall effectuate the suspension of payments to the

provider unless prior notice of the payment suspension is necessary. When prior notice is

necessary, the MAC shall effectuate the suspension of payment in concert with the

established date from the payment suspension notice.

For all payment suspensions, the UPIC shall request the MAC implement a “payment

suspension” or “partial payment suspension” when applicable. For all payment

suspensions and emergency payment suspensions, the MAC shall no longer use "F_Fraud

and Abuse", “F_CMS Request” or “P_CMS Request” HIGLAS hold reason codes for

UPIC requested payment suspension activities. MACs shall only use "F_PSC Request"

(Full Hold) or “P_PSC Request”(Partial Hold) HIGLAS hold reason codes going forward

for all UPIC requested payment suspension and emergency payment suspension

activities.

UPICs shall not request that MACs create placeholder debts or “escrow amounts” based

on anticipated provider settlements. The MAC shall no longer create these debts in

HIGLAS. If a UPIC requests a MAC to create a placeholder debt, the MAC shall reach

out to OFM for guidance before any action is taken.

The MACs shall ensure that all money on the payment floor is not released to the

provider after the effective date of the suspension and the money is withheld in

accordance with the payment suspension rules and regulations. MACs shall provide an

accounting of the money withheld on day one of the payment suspension to the UPIC.

The UPIC shall enter this amount in the UCM as the first monetary entry.

Unless otherwise specified, when a payment suspension is imposed, no payments are to

be released to the provider as of the effective date of the payment suspension. This

includes payments for new claims processed, payments for adjustments to claims

previously paid, interim PIPs. If it is discovered that money is released to the provider

after the effective date of the payment suspension, the MAC or UPIC shall contact CPI

for guidance.