CMS Pub. 100-08, ch. 9, § 9.9

Program

(Rev. 921, Issued: 11-06-19 Effective: 11-04- 19, Implementation: 11-04-19)

Section 302 of the Tax Relief and Health Care Act of 2006 allows CMS to pay for all

costs associated with conducting the RAC Program out of RAC collections. These costs

are not attributed to a contractor’s annual budget. These costs are only attributed to the

RAC Program and are paid from RAC collections. The CMS has created two activity

codes for the RAC program. The MAC shall use these codes for all activities related to

the RAC Program. Detailed descriptions of the activity codes and what may be included

are below.

Activity Code 11031 – RAC Implementation and Maintenance Activities

These duties include:

- Completion and maintenance of a JOA with the applicable RAC(s)

- Adjusting all claims identified by the RAC as containing an underpayment or an

overpayment

- Performing validation of overpayment identifications if requested by CMS

- Creating and maintaining accounts receivables for RAC identified overpayments

- Collecting and processing monies received for RAC identified overpayments

- Processing offset for RAC identified overpayments

- Performing necessary provider education relevant to the operation of the RAC program

if requested by CMS

- Creating exclusion files for upload to the RACDW

- Creating monthly/daily reports for upload to the RACDW

- Creating monthly/daily reports for feedback to the RAC

- Communicating with RACs and CMS

- Handling RAC related inquires

- Handling activities associated with withdrawing an overpayment not resulting from an

appeal

Activity Code 12031 – RAC Initiated Appeal Activities

These duties include:

- Performing and adjudicating the redetermination

- Reporting appeals statistics to the CMS RAC COR or delegate

- Handling inquiries from CMS regarding RAC-identified overpayments

- Attending meetings with the RAC and/or the CMS COR

- Handling records, notes and documents regarding RAC and Provider appeals

- Processing and tracking all appeals for RAC identified overpayments and creating

appeal reports for upload to the RACDW if requested by CMS

- Communicating with RACs and CMS

- Communicating with other appeal entities on RAC identified overpayment cases

Qualified Independent Contractor (QIC), Administrative Law Judge

(ALJ), Departmental Appeals Board (DAB)