CMS Pub. 100-08, ch. 9, § 9.2.4

RACs that refer a complaint to the UPIC shall notify the UPIC via e-mail that a

complaint is being referred as potentially fraudulent. The RAC shall develop a referral

package (see below for what should be included in the referral package) for all

complaints being referred to the UPIC and shall send the complaint via a secure method

such as e-mail or mail directly to the UPIC. Complaints shall be forwarded to the UPIC

for further review under the circumstances listed below (this is not an exhaustive list):

• Claims may have been altered

• Claims have been up-coded to obtain a higher reimbursement amount and

appear to be fraudulent or abusive;

• Potential misrepresentation with respect to the nature of the services rendered,

charges for the services rendered, identity of the person receiving the services,

identity of persons or doctor providing the services, dates of the services, etc.;

• Alleged submissions of claims for non-covered services are misrepresented as

covered services, excluding demand bills and those with Advanced Beneficiary

Notices (ABNs);

• Claims involving potential collusion between a provider/supplier and a

beneficiary resulting in higher costs or charges to the Medicare program;

• Alleged use of another person’s Medicare number to obtain medical care;

• Alleged alteration of claim history records to generate inappropriate payments;

• Alleged use of the adjustment payment process to generate inappropriate

payments; or

• Any other instance that is likely to indicate a potential fraud, waste, and abuse

situation.

NOTE: Since this is not an all-inclusive list, the UPIC has the right to request additional

information in the resolution of the complaint referral or the subsequent development of a

related case (e.g., provider/supplier enrollment information).

When the above situations occur requiring that the complaint be referred to the UPIC for

review, the RAC shall prepare a referral package that includes, at a minimum, the

following:

• Provider/supplier name, NPI, provider/supplier number, and address.

• Type of provider/supplier involved in the allegation and the perpetrator, if an

employee of the provider/supplier.

• Type of service involved in the allegation.

• Place of service.

• Nature of the allegation(s).

• Timeframe of the allegation(s).

• Date of service, procedure code(s).

• Beneficiary name, beneficiary HICN, telephone number.

NOTE: Since this is not an all-inclusive list, the UPIC has the right to request additional

information in the resolution of the complaint referral or the subsequent development of a

related case (e.g., provider/supplier enrollment information). The RAC shall maintain a

copy of all referral packages.