CMS Pub. 100-08, ch. 9, § 9.4

The MAC, Supplemental Medical Review Contractor (SMRC), CERT, and Unified

Program Integrity Contractor (UPIC) shall input all claims requiring suppression and

exclusion into the RACDW. An exclusion is the permanent removal of a claim due to a

previous review. A suppression is a temporary removal of a claim to an ongoing case

development. The UPIC shall refer to their specific suppression and/or exclusion

requirements in IOM-100-8 Chapter 4. The MAC can permanently exclude an individual

claim or a series of claims, or suppress a provider’s claim submission for a particular

claim type for a period of time not to exceed one calendar year.

The following cases require exclusion:

• A medical review is in progress; or claims subjected to post payment review;

• Claims subjected to prepayment medical review;

• Claims originally denied and later paid by an appeal entity

The following cases require suppression:

• A fraud/program integrity review is in progress;

• The MAC or UPIC has been notified by an outside agency (law

enforcement, Office of Inspector General (OIG), Department of Justice

(DOJ)) that an investigation is ongoing.

The MACs shall not suppress or exclude claims that do not meet the above criteria.

Claims on which the MAC is conducting education should not be suppressed.

The MACs shall enter suppression and/or exclusion records immediately after the need

for these actions are identified. After the initial data input, contractors shall consistently

monitor the RACDW and update on an as needed basis.

The MACs shall keep documentation on file that supports the information they added to

the RACDW.

NOTE: The suppression or exclusion of an entire provider will require CMS approval.

Additional direction can be found in the Medicare Program Integrity Manual (MPIM),

Publication 100-08, Chapter 3, Section 3.5.2, and Chapter 4, Section 4.7.4.