CMS Pub. 100-08, ch. 8, § 8.3.2.2.5

If the payment suspension is approved with prior notice, the provider is afforded an

opportunity to submit to the UPIC a statement within 15 calendar days indicating why

the payment suspension action should not be imposed. However, this time may be

shortened or lengthened for cause. (See 42 CFR §405.374(b).)

If the payment suspension is approved without prior notice, the provider is also afforded

an opportunity to submit to the UPIC a statement as to why the payment suspension

action should not be imposed. (See 42 CFR §405.372(b)(2).) For purposes of consistency

for both prior notice and no prior notice, CMS/CPI suggests that a 15 calendar day

response time be established for the provider.

If a provider submits a rebuttal timely, a timely determination and written response by

the UPIC is required in accordance with 42 CFR §405.375. If a provider does not

respond in a timely manner, the UPIC shall submit a written response to the provider

within 30 calendar days from the receipt date of the rebuttal.

UPICs shall ensure the following:

• CMS Review – UPICs shall forward the provider’s rebuttal statement and

any pertinent information to CPI via the UCM within 1 business day of

receipt. The UPIC shall evaluate the information presented and then draft a

response addressing each item mentioned in the rebuttal and submit it to CPI for

approval via the UCM no later than 10 calendar days from receipt. The UPIC may

contact CPI for guidance before drafting a response.

• Timing –The payment suspension shall go into effect as indicated in the

notice.

• Review of Rebuttal – Because payment suspension actions are not

appealable, the rebuttal is the provider’s only opportunity to present

information as to why suspension action should not be initiated or should be

terminated. UPICs shall carefully review the provider’s rebuttal statement

and pertinent information, and shall consider all facts and issues raised by the

provider. If the UPIC is convinced that the payment suspension action should

not be initiated or should be terminated, it shall consult with the CPI for

guidance.

• Response – CMS is obligated to consider the initial rebuttal and supportive

information received from the provider and to make a determination within

15 calendar days from receipt of the rebuttal. (See 42 CFR §405.375(a).) If a

full response cannot be drafted in the required timeframe, the UPIC shall

draft an interim response for release that is approved by CPI.