CMS Pub. 100-08, ch. pim83exhibits, § 40.1

Fld. No. of

No. Position Cols. Item Description Comments

1. 001 1 Record Code

9(01)

9 = Trailer Record

2. 002-006 5 Incoming

Carrier

Number 9(05)

CMS Contractor Number;

Multistate Contractors Use

The Distinct Number Of

Each Jurisdiction

3. 007-014 6 File

Creation9(06)

(MMDDYYYY) Month,

Day, And Year Of File

Creation.

4. 015-029 15 Number of

Records Sent

9(15)

Total Number Of Records

On The File. Do Not

Include The Trailer

Record.

Right justified and precede

with zeroes.

5. 030-306 273 Filler X(277)

NOTE: For "9" numeric fields, show zeroes if blank. For all "X" alpha numeric fields, if no information

leave field blank.

Exhibit 41.1 - List of Medical School in the U.S.

(Rev. 141, Issued: 02-24-06; Effective/Implementation: N/A)

LIST OF MEDICAL SCHOOLS IN THE U.S.

ALABAMA

00102 University of Alabama School of Medicine, Birmingham, AL 3529

00104 Birmingham Medical College

00106 University of South Alabama College of Medicine, Mobile, AL 37788

ARIZONA

00301 University of Arizona College of Medicine, Tucson, AZ 85724

ARKANSAS

00401 University of Arkansas College of Medicine, Little Rock, AR 77205

00402 College of Physicians and Surgeons, Little Rock, AR 77205

CALIFORNIA

00501 Cooper Medical College, San Francisco, CA 94143

00502 University of California, San Francisco School of Medicine, San Francisco, CA 94143

00504 California Eclectic Medical College, Los Angeles, CA 90033

00505 Hahneman Medical College of the Pacific, San Francisco, CA 94305

00506 University of Southern California School of Medicine, Los Angeles, CA 90033

00507 College of Physicians and Surgeons of San Francisco, CA

00508 Oakland College of Medicine and Surgery

00509 College of Physicians and Surgeons, Los Angeles, CA 90024

00511 Stanford University School of Medicine, Palo Alto, CA 94305

00512 Loma Linda University School of Medicine, Loma Linda, CA 92350

00513 Pacific Medical College, Los Angeles

00514 University of California, UCLA School of Medicine, Los Angeles, CA 90024

00515 University of California, California College of Medicine, Irvine, CA 92717

00516 University of California, Irvine, California College of Medicine Irvine, CA 92717

00517 University of California, Irvine, California College of Medicine, Irvine, CA 92717

00518 University of California, San Diego School of Medicine, La Jolla, CA 92093

00519 University of California, Davis School of Medicine, Davis, CA 95616

00576 College of Osteo of the Pacific, Pomona, CA 91766

COLORADO

00702 University of Colorado School of Medicine, Denver, CO 80262

00705 Denver and Gross College of Medicine Denver, CO 80262

CONNECTICUT

00801 Yale University School of Medicine, New Haven, CT 06510

00802 University of Connecticut School of Medicine, Farmington, CT 06032

DISTRICT OF COLUMBIA

01001 George Washington University School of Medicine, Washington, DC 20037

01002 Georgetown University School of Medicine, Washington, DC 20007

01003 Howard University College of Medicine, Washington, DC 20059

FLORIDA

01102 University of Miami School of Medicine, Miami, FL 33101

01103 University of Florida College of Medicine, Gainesville, FL 32610

01104 University of South Florida College of Medicine, Tampa, FL 33612

01175 Southeastern College of Osteo Medicine, Miami, FL 33162

GEORGIA

01201 Medical College of Georgia, Augusta, GA 30912

01205 Emory University School of Medicine, Atlanta, GA 30322

01209 Georgia College of Eclectric Medicine and Surgery, Atlanta, GA 30314

01211 Atlanta College of Physicians and Surgeons, Atlanta, GA 30322

01212 Atlanta School of Medicine Atlanta, GA 31207

01218 Hospital Medical College Eclectric, Atlanta, GA 31207

01219 Southern College of Medicine and Surgery, Atlanta, GA 30314

01221 Morehouse School of Medicine, Atlanta, GA 31207

01222 Mercer University School of Medicine, Macon, GA 31207

HAWAII

01401 University of Hawaii John A. Burns School of Medicine, Honolulu, HI 96822

ILLINOIS

01601 Rush Medical College of Rush University, Chicago, IL 60612

01602 University of Chicago, Pritzker School of Medicine, Chicago, IL 60637

01604 The Hahneman Medical College and Hospital, Chicago, IL 60637

01605 College of Medicine and Surgery, Chicago, IL 60658

01606 Northwestern University Medical School, Chicago, IL 60611

01608 Bennett Medical College, Chicago, IL 60639

01609 Northwestern University Women Medical School, Chicago, IL 60637

01610 Chicago Homeopathic Medical College, Chicago, IL 60612

01611 University of Illinois at Chicago Health Science Center, Chicago, IL 60612

01613 Harvey Medical College, Chicago, IL 60637

01614 National Medical University, Chicago 60639

01615 Hering Medical College, Chicago, IL 60638

ILLINOIS

01616 Jenner Medical College, Chicago, IL 60637

01617 Illinois Medical College, Chicago, IL 60637

01618 Dunham Medical College, Chicago, IL 60637

01619 American Medical Missionary College, Battle Creek, Chicago, IL 60637

01622 Chicago College of Medicine and Surgery

01623 Dearborn Medical College, Chicago, IL 60637

01642 University of Health Sciences/ Chicago Medical School, North Chicago, IL 60064

01643 Loyola University of Chicago, Stitch School of Medicine, Maywood, IL 60153

01644 The General Medical College, Chicago, IL 60615

01645 Southern Illinois University School of Medicine, Springfield, IL 62708

01675 Chicago College of Osteopathy, Chicago, IL 60615

INDIANA

01705 Physiological Medical College of Indiana, Indianapolis, IN 46202

01708 Medical College of Indiana, Indianapolis, IN 46224

01709 Central College of Physicians and Surgeons, Indianapolis, IN 46223

01717 Eclectic Medical College of Indiana, Indianapolis, IN 46224

01718 Indiana Medical College, Indianapolis, IN 46224

INDIANA

01719 School of Medicine of Purdue University, Indianapolis, IN 46202

01720 Indiana University School of Medicine, Indianapolis, IN 4622

IOWA

01801 College of Physicians and Surgeons, Keokuk, IA 52632

01803 University of Iowa College of Medicine, Iowa City, IA 52242

01804 State University of Iowa College of Homeopathic Medicine, Iowa City, IA 52242

01806 Drake University College of Medicine, Des Moines, IA 50311

01808 Sioux City College of Medicine, Sioux City, IA 50312

01810 Keokuk Medical College, College of Physicians and Surgeons, Keokuk, IA 52632

01875 University of Osteopathic Medicine and Health Sciences, Des Moines, IA 50312

KANSAS

01902 University of Kansas School of Medicine, Kansas City, KS 66103

01903 Kansas Medical College, Topeka, KS 66606

01904 College of Physicians and Surgeons, Kansas City, KS 66110

01907 Western Eclectic College of Medicine and Surgery, Kansas City, KS 66102

KENTUCKY

02001 Kentucky School of Medicine, Louisville, KY 40292

02002 University of Louisville School of Medicine, Louisville, KY 40292

02004 Louisville Medical College, Louisville, KY 40292

02005 Hospital College of Medicine, Louisville, KY

KENTUCKY

02006 Louisville National Medical College, Louisville, KY 40292

02008 Southwestern Homeopathic Medical College and Hospital, Louisville, KY 40546

02009 Kentucky University Medical Department, Louisville, KY 40292

02011 Louisville Hospital Medical College, Louisville, KY 40292

02012 University of Kentucky College of Medicine Lexington, KY 40536

LOUISIANA

02101 Tulane University School of Medicine, New Orleans, LA 70112

02104 Flint Medical College of New Orleans University, New Orleans, LA 70112

02105 Louisiana State University School of Medicine in New Orleans, New Orleans, LA 70112

02106 Louisiana State University School of Medicine in Shreveport, Shreveport, LA 71130

MAINE

02201 Bowdoin Medical School, Brunswick-Portland ME 04003

02275 University of New England, College of Osteo Medicine, Biddeford, ME 04005

MARYLAND

02301 University of Maryland School of Medicine, Baltimore, MD 21201

02303 College of Physicians and Surgeons of Baltimore, Baltimore, MD 21201

02304 Baltimore Medical College, Baltimore, MD 21201

02305 Womans Medical College of Baltimore, Baltimore, MD 21201

02306 Baltimore University School of Medicine, Baltimore, MD 21201

02307 Johns Hopkins University School of Medicine, Baltimore, MD 21205

02308 Atlantic Medical College, Baltimore, MD 21201

02309 Maryland Medical College, Baltimore, MD 21201

02311 Maryland College of Eclectic Medicine and Surgery, Baltimore, MD 21201

02312 Uniformed Services University of the Health Sciences, Bethesda, MD 20014

MASSACHUSETTS

02401 Harvard Medical School, Boston, MA 02115

02405 Boston University School of Medicine, Boston, MA 02118

02406 College of Physicians and Surgeons, Boston, MA 02111

02407 Tufts University School of Medicine, Boston, MA 02111

02415 Middlesex University School of Medicine, Waltham, MA 02154

02416 University of Massachusetts Medical School, Worcester, MA 01605

MICHIGAN

02501 University of Michigan Medical School, Ann Arbor, MI 48109

02505 University of Michigan Homeopathic Medical School, Ann Arbor, MI 48209

02507 Wayne State University School of Medicine, Detroit, MI 48201

02508 Michigan College of Medicine and Surgery, Detroit, MI 48201

02512 Michigan State University College of Human Medicine, East Lansing, MI 48824

02576 Michigan State University College of Osteopathic Medicine, East Lansing, MI 48824

MINNESOTA

02604 University of Minnesota Medical School, Minneapolis, MN 55455

02605 Minneapolis College of Physicians and Surgeons

02607 University of Minnesota, Duluth School of Medicine, Duluth, MN 55812

02608 Mayo Medical School, Rochester, MN 55905

MISSISSIPPI

02701 University of Mississippi School of Medicine, Jackson, MS 39216

02702 Mississippi Medical College, Meridian, MS 39305

MISSOURI

02801 Missouri Medical College, St. Louis, MO 63110

02802 Washington University School of Medicine, St Louis, MO 63110

02803 University of Missouri, Columbia School of Medicine, Columbia, MO 65212

02805 Homeopathic Medical College of Missouri, St. Louis, MO 63141

02807 St. Louis College of Physicians and Surgeons

02808 Kansas City Medical College

02810 National University of Arts and Sciences Medical Department, St. Louis, MO 63110

02820 University Medical College of Kansas City Kansas City, MO 64111

02822 Ensworth Medical College, St. Joseph, MO 64507

02826 Kansas City Homeopathic Medical College

02828 Barnes Medical College, St. Louis, MO 63110

02830 Woman's Medical College, Kansas City, MO 63111

02833 Eclectic Medical University, Kansas City, MO 63111

02834 Saint Louis University School of Medicine, St Louis, MO 63104

02835 Southwest School of Medicine and Hospital, Kansas City, MO 63111

02843 Kansas City College of Medicine and Surgery

02844 Kansas City University of Physicians and Surgeons

02845 Mid West Medical College, Kansas City, MO (See 02843)

02846 University of Missouri, Kansas City School of Medicine, Kansas City, MO 64108

02878 The University of Health Sciences, College of Osteo Medicine, Kansas City, MO 64124

02879 Kirksville College of Osteopathic Medicine, Kirksville, MO 63501

NEBRASKA

03004 Lincoln Medical College, Eclectic, Lincoln, NE 68501

03005 University of Nebraska College of Medicine, Omaha, NE 68105

03006 Creighton University School of Medicine, Omaha, NE 68178

03007 Nebraska College of Medicine, Lincoln, NE 69508

NEVADA

03101 University of Nevada School of Medicine, Reno, NV 89507

NEW HAMPSHIRE

03201 Dartmouth Medical School, Hanover, NH 03756

NEW JERSEY

03305 UMDNJ-New Jersey Medical School, Newark, NJ 07103

03306 UMDNJ-Robert Wood Johnson Medical School, Piscataway, NJ 08854

03375 UMDNJ New Jersey School of Osteo Medicine, Camden, NJ 08103

NEW MEXICO

03401 University of New Mexico School of Medicine, Albuquerque, NM 87131

NEW YORK

03501 Columbia University College of Physicians and Surgeons, New York, NY 10032

03503 Albany Medical College of Union University, Albany, NY 12208

03506 State Univesity of New York at Buffalo School of Medicine, Buffalo, NY 14214

03508 State University of New York Downstate Medical Center, Brooklyn, NY 12203

03509 New York Medical College, Valhalla, NY 10595

03510 Bellevue Hospital Medical College, New York, NY 10016

03511 New York Medical College and Hospital for Women, New York 10025

03513 Eclectic Medical College of the City of New York

03515 State University of New York Health Science Center of Syracuse, Syracuse, NY 13210

03519 New York University School of Medicine, New York, NY 10016

03520 Cornell University Medical College, New York, NY 10021

03543 Fordham University School of Medicine, New York, NY 10027

03545 University of Rochester School of Medicine and Dentistry, Rochester, NY 14642

03546 Albert Einstein College of Medicine of Yeshiva University, New York, NY 10461

03547 Mount Sinai School of Medicine of City University of New York, New York NY 10029

03548 State University of New York at Stony Brook, School of Medicine, Stony Brook, NY

11794

03575 New York College of Osteo Medicine of New York Institute of Technology, Old

Westbury, NY 11568

NORTH CAROLINA

03601 University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27514

03603 Leonard Medical School, Raleigh, NC 27604

03604 North Carolina Medical College, Charlotte, NC 28223

03605 Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, NC

27103

03607 Duke University School of Medicine, Durham, NC 27710

03608 East Carolina University School of Medicine, Greenville, NC 27834

NORTH DAKOTA

03701 University of North Dakota School of Medicine, Grand Forks, ND 58201

OHIO

03801 Medical College of Ohio, Cincinnati, OH 44115

03802 Eclectic Medical College, Cincinnati, OH 44115

03803 Starling Medical College, Columbus, OH 45210

03806 Case Western Reserve University School of Medicine, Cleveland, OH 44206

03808 Cincinnati College of Medicine and Surgery

03809 Miami Medical College, Cincinnati, OH 44106

03811 University of Wooster Medical Department, Cleveland, OH 44206

03819 Toledo Medical College

03823 Cleveland Medical College, Homeopathic Cleveland, OH 45210

03825 Ohio Medical University Columbus, OH 45210

03826 Cleveland Pulte Medical College

03840 Ohio State University College of Medicine, Columbus, OH 43210

03841 University of Cincinnati College of Medicine, Cincinnati, OH 45267

03843 Medical College of Ohio at Toledo, Toledo, OH 43699

03844 Northeastern Ohio Universities College of Medicine, Rootstown, OH 44272

03845 Wright State University School of Medicine, Dayton, OH 45401

03875 Ohio University of Osteo Medicine, Athens, OH 45701

OKLAHOMA

03901 University of Oklahoma College of Medicine, Oklahoma City, OK 73190

03905 Oral Roberts University School of Medicine, Tulsa, OK 74171

03979 Oklahoma College of Osteopathic Medicine and Surgery, Tulsa, OK 47127

OREGON

04001 Williamette University Medical Department, Salem, OR 97304

04002 Oregon Health Sciences University School of Medicine, Portland, OR 97201

PENNSYLVANIA

04101 University of Pennsylvania School of Medicine, Philadelphia, PA 19104

04102 Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA 19107

04107 Medical College of Pennsylvania, Philadelphia, PA 19129

04109 Hahnemann University College of Medicine, Philadelphia, PA 19102

04111 Medico Chirurgical College of Philadelphia, Philadelphia, PA 19102

04112 University of Pittsburgh School of Medicine, Pittsburgh, PA 15261

04113 Temple University School of Medicine, Philadelphia, PA 19140

04114 Pennsylvania State University College of Medicine, Hershey, PA 17033

04177 Philadelphia College of Osteopathic Medicine, Philadelphia, PA 191431

PUERTO RICO

04201 University of Puerto Rico School of Medicine, San Juan, PR 00936

04202 Ponce School of Medicine, Ponce, PR 00732

04203 Universidad Central del Caribe Escuela de Medicina, Cayey, PR 00633

04204 University De Ciencias Med San Juan Bautista, Hato Rey, PR 00917

RHODE ISLAND

04301 Brown University Program in Medicine, Providence, RI 02912

SOUTH CAROLINA

04501 Medical University of South Carolina College of Medicine, Charleston, SC 29425

04504 University of South Carolina School of Medicine, Columbia, SC 29208

SOUTH DAKOTA

04601 University of South Dakota School of Medicine, Vermillion, SD 57069

TENNESSEE

04701 University of Nashville Medical Department

04705 Vanderbilt University School of Medicine, Nashville, TN 37232

04706 University of Tennessee College of Medicine, Memphis, TN 38163

04707 Meharry Medical College School of Medicine, Nashville, TN 37208

04708 Memphis Hospital Medical College

04709 Chattanooga Medical College

04710 Lincoln Memorial University Medical Department, Knoxville, TN 37920

04711 University of the South Medical Department, Sewanee, TN 37375

04713 Knoxville Medical College

04714 University of West Tennessee College of Medicine and Surgery, Memphis, TN 37402

04715 College of Physicians and Surgeons, Memphis, TN 37208

04720 East Tennessee State University, Quillen-Dishner College of Medicine, Johnson City, TN

37614

TEXAS

04802 University of Texas Medical Branch at Galveston, Galveston, TX 77550

04803 Fort Worth School of Medicine

04804 Baylor College of Medicine, Houston, TX 77030

04805 Physiological Medical College of Texas, Dallas, TX 76203

04806 Southern Methodist University Medical Department, Dallas, TX

04807 Gate City Medical College, Dallas, TX 76204

04812 University of Texas Southwestern Medical School at Dallas, Dallas, TX 75235

04813 University of Texas Medical School at San Antonio, San Antonio, TX 78284

04814 University of Texas Medical School at Houston, Houston, TX 77225

04815 Texas Tech University Health Science Center School of Medicine, Lubbock, TX 79430

04816 Texas A & M University College of Medicine, College Station, TX 77843

04878 Texas College of Osteopathic Medicine, Lubbock, TX 79430

UTAH

04901 University of Utah School of Medicine, Salt Lake City, UT 84132

VERMONT

05002 University of Vermont College of Medicine, Burlington, VT 05405

VIRGINIA

05101 University of Virginia School of Medicine, Charlottesville, VA 22908

05104 Medical College of Virginia Commonwealth University School of Medicine, Virginia,

Richmond, VA 23298

05106 University College of Medicine, Richmond, VA 23298

05107 Eastern Virginia Medical School, Norfolk, VA 23501

WASHINGTON

05404 University of Washington School of Medicine, Seattle, WA 98195

05415 Washington College of Physicians and Surgeons, Seattle, WA 98196

WEST VIRGINIA

05501 West Virginia University School of Medicine, Morgantown, WV 26506

05502 Marshall University School Medicine, Huntington, WV 25701

05575 West Virginia School of Osteopathic Medicine, Lewisburg, WV 24901

WISCONSIN

05602 Wisconsin College of Physicians and Surgeons, Milwaukee, WI 53226

05603 Milwaukee Medical College

05605 University of Wisconsin Medical School, Madison, WI 53706

05606 Medical College of Wisconsin, Milwaukee, WI 53226

This list of codes for medical schools in the U.S. is copyrighted by the American Medical

Association. Carrier use is restricted to CMS requirements in the physician identification effort.

Copyright 1987

American Medical Association

535 North Dearborn Street

Chicago, IL 60610

All Rights Reserved

Additional copies

may be purchased from:

Book & Pamphlet Fulfillment OP-167/7

American Medical Association

P.O. Box 10946

Chicago, IL 60610

HNA: 86-818:33M:2/87

USBN 0-89970-237-6

ISSN 0892-0109

Exhibit 41.2 - Directory of Podiatric Medical Colleges

(Rev. 141, Issued: 02-24-06; Effective/Implementation: N/A)

DIRECTORY OF PODIATRIC MEDICAL COLLEGES

30000 California College of Podiatric Medicine

1210 Scott St., San Francisco, CA 94120

30100 Dr. William M. Scholl School of College of Podiatric Medicine

1001 North Dearborn St., Chicago, IL 60610

30200 New York College of Podiatric Medicine

53 East 124th St., New York, NY 10035

30300 Ohio College of Podiatric Medicine

10515 Carnegie Ave., Cleveland, OH 44106

30400 Pennsylvania College of Podiatric Medicine

Eighth at Rale St, Philadelphia, PA 19107

30500 Barry University School of Podiatric Medicine

11300 Northeast Second Ave., Miami Shores, FL 33161

30600 College of Podiatric Medicine and Surgery,

University of Osteopathic Medicine and Health Sciences

3200 Grand Ave., Des Moines, IA 50312

Exhibit 41.3 - American Optometric Association Council on Optometric

Education

(Rev. 141, Issued: 02-24-06; Effective/Implementation: N/A)

List of Accredited Professional Optometric Degree Programs

June 1986

40000 University of Alabama in Birmingham

School of Optometry

Birmingham, AL 35292

40010 University of California

School of Optometry

Minor Hall

Berkley, Ca 94720

40020 Ferris State College

College of Optometry

Big Rapids, MI 49307

AMERICAN OPTOMETRIC ASSOCIATION

COUNCIL ON OPTOMETRIC EDUCATION

40030 University of Houston

College of Optometry

Houston, TX 77004

40040 Illinois College of Optometry

3241 South Michigan Avenue

Chicago, IL 60616

40050 Indiana University

School of Optometry

Bloomington, IN 47405

40060 Inter-American University of Puerto Rico

School of Optometry

San Juan, PR 00936

40070 University of Missouri

St. Louis, MO 63121

40080 University of Montreal

School of Optometry

Montreal, P.Q.

Canada H3C 3J7

40090 New England

College of Optometry

Boston, MA 02115

40100 Berkeley Northeastern State University

College of Optometry

Tahlequah, Ok 74464

40110 State University of NY

State College of Optometry

New York, NY 10010

40120 The Ohio State University

College of Optometry

Columbus, OH 43210

40130 Pacific University

College of Optometry

Forest Grove, OR 97116

40140 Pennsylvania College of Optometry

Philadelphia, PA 19141

40150 South California College of Optometry

Fullerton, CA 96231

40160 Southern College of Optometry

Memphis, TN 38104

40170 University of Waterloo

School of Optometry

Waterloo, Ontario

Canada N2L 3G1

Exhibit 41.4 - List of Chiropractic Schools in the U.S.

(Rev. 141, Issued: 02-24-06; Effective/Implementation: N/A)

List of Chiropractic Schools in the U.S

Code

50010 Adio Institute of Straight Chiropractic

Levittown, PA 19056

Changed name to Pennsylvania College of Straight Chiropractic - (1984)

50020 Atlantic States Chiropractic Institute

Brooklyn, NY 10021

Merged with Columbia Institute of Chiropractic

50030 Bebout College of Chiropractic

Indianapolis, IN 46224

50040 Booker T. Washington Chiropractic College

Kansas City, MO 66103 50050

50050 Logan College

Oklahoma City, OK 73190

Formerly Carver-Denny Chiropractic

College Merged with Logan College of Chiropractic - (1958)

50060 Los Angeles College of Chiropractic

Formerly California Chiropractic College

(1963) Los Angeles, CA 90024

50065 Central States College of Physiatrics and

Chiropractic Eaton, OH 45320

50070 Canadian Memorial Chiropractic College

Toronto, Ontario M4G 3E6 50080

50080 Chiropractic Institute of New York

New York, NY 10022

50090 Crisco Chiropractic College (Proposed)

Crisco, TX 77650

* Schools in business since 1950

**Schools not listed use code 5000

50100 Cleveland Chiropractic College

Los Angeles, CA 90004

50110 Cleveland Chiropractic College

Kansas City, MO 64131

50120 Columbia College of Chiropractic

Baltimore, MD 21201

50130 Columbia College of Chiropractic

Alameda, CA 94501

50140 Columbia College of Chiropractic

and Naturopathy Sacramento, CA 95860

50150 Columbia Institute of Chiropractic

New York, NY 10025

50160 Hollywood College of Chiropractic

Hollywood, CA 90024

50170 Lafayette Institute

Philadelphia, PA 19104

50180 Life Chiropractic College

San Lorenzo, CA 94580

50190 Lincoln Chiropractic College

Marietta, GA 30060

50200 Reaver School of Chiropractic

Dayton, OH 45401

50210 Restview Chiropractic College

University of Chiropractic

Seattle, WA 98196

50220 San Francisco College of Chiropractic

San Francisco, CA 94128

Formerly West Coast Chiropractic

College; Name changed to Metropolitan

College of Chiropractic - 1944

50230 Sherman College of Straight Chiropractic, Spartanburg, SC 29304

50240 Western States College of Chiropractic, Portland, OR 97230

50250 University of Pasadena, College of Chiropractic, Pasadena, CA 91108

50260 University of Natural Healing Arts, Denver CO 80262

50270 National College of Chiropractic, Lombard IL 60148

50280 New York Chiropractic College, Glen Head, NY 11545

50290 Northwestern College of Chiropractic, Bloomington, MN 55431

50300 Palmer College of Chiropractic – West, Sunnyvale, CA 94087

50310 Palmer College of Chiropractic, Davenport, IA 52803

Exhibit 42 - Sanction Codes

(Rev. 141, Issued: 02-24-06; Effective/Implementation: N/A)

Sanction Codes *

CODE DESCRIPTION

A - 1128(a)(1) - Program-related conviction

B - 1128(a)(2) - Conviction for patient abuse or neglect

C - 1128(b)(1) - Conviction relating to fraud

D - 1128(b)(2) - Conviction relating to obstruction of an investigation

E - 1128(b)(3) - Conviction relating to controlled substances

F - 1128(b)(4) - License revocation or suspension

G - 1128(b)(5) - Suspension or exclusion under a Federal or State health care program

H - 1128(b)(6) - (Formerly 1862(d)(1)(B) and (C)) - Excessive claims or furnishing of

unnecessary or substandard items or services

I - 1128(b)(7) - Fraud, kickbacks and other prohibited activities

(including 1162(d)(1A))

J - 1128(b)(8) - (Formerly 1128(b) - Entities owned or controlled by a sanctioned

individual

K - 1128(b)(9) Failure to disclose required information

L - 1128(b)(10) - Failure to supply requested information on subcontractors and suppliers

M -1128(b)(11) - Failure to provide payment information

N - 1128(b)(12) - Failure to grant immediate access

O - 1128(b)(13) - Failure to take corrective action

P - 1128(b)(14) - Default on health education loan or scholarship obligations

Q - 1128Aa - (Formerly 1128(c) - Imposition of a civil money penalty or assessment

R - 1156(b) - (Formerly 1160) - PRO recommendation

U - - UNKNOWN (Physician is sanctioned, but type of sanction unknown)

* If a physician has more than one sanction, show the code of the sanction with the longest

duration.

Exhibit 43 - Carrier Transmittal Sheet

(Rev. 141, Issued: 02-24-06; Effective/Implementation: N/A)

______________________________________________________________________

A.

UPIN Carrier Data Transmittal

______________________________________________________________________

Deliver to: 1. Carrier Number:

2. *Name and Address of Carrier

______________________________________________________________________

UPIN Records Included in this Transmittal

______________________________________________________________________

3. Date Prepared: 4. Date Shipped:

______________________________________________________________________

B. 1 UPIN Data Records: Tape Diskette

Volume Serial Number: ____________________________

____________________________

____________________________

____________________________

____________________________

____________________________

______________________________________________________________________

B. 2 Total Records

______________________________________________________________________

B. 3 Type Records:

Medical Doctor/D.O. Records

Other Doctor Records

______________________________________________________________________

C. 1

We have successfully processed the above file

(no reel will be returned).

______________________________________________________________________

C. 2

We are unable to accept your UPIN Data Records.

See below for information on reason for return.

______________________________________________________________________

Reason for return:

______________________________________________________________________

* Enter complete name and address of persons to whom all questions may be addressed.

______________________________________________________________________

Exhibit 44

(Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20)

Standard Core

Joint Operating Agreement

Between

RACs and UPICs

Recovery Audit Contractors (RACs)

Unified Program Integrity Contractors (UPICs)

Revision History Log

Version Date Changed By Description of Change Approval

Required

V01

V02

Table of Contents

1. Introduction 275

1.1. Purpose of this JOA........................................................................................ 275

1.2. Parties ................................................................................................................. 5

1.3. Jurisdictions, Contacts, Roles, and Responsibilities .......................................... 5

1.4. Confidentiality ................................................................................................ 275

1.5. Liability .......................................................................................................... 275

1.6. Funding............................................................................................................... 5

2. Document Maintenance 276

2.1. Standard Core JOA ......................................................................................... 276

2.2. JOA Appendices ............................................................................................. 276

2.3. Required Roles ............................................................................................... 276

2.4. Managing Change .......................................................................................... 277

2.5. Approval of Standard Core JOA .................................................................... 277

3. Communication 279

3.1. JOA Checkpoint Meetings ............................................................................. 279

3.2. Other Workgroup Meetings ........................................................................... 279

3.3. Issue Escalation and Resolution Process ........................................................ 279

3.4. Non-Compliance ............................................................................................ 280

3.5. Communication Regarding CMS Changes .................................................... 280

4. Securing Email Information 281

5. Identification and Action on Fraudulent Behavior 282

5.1. Identification and Notification of Fraud by the RAC ..................................... 282

5.2. Coordination with Law Enforcement ............................................................. 282

5.3. High Risk Areas ............................................................................................. 282

6. Training 283

6.1. Training provided by the UPIC ...................................................................... 283

1. Introduction

1.1. Purpose of this JOA

This Joint Operating Agreement (JOA) is designed to promote cooperation between Recovery

Audit Contractors (RACs) and the Unified Program Integrity Contractor (UPIC) by establishing

and maintaining shared expectations for the interaction among these Parties to the JOA.

1.2. Parties

Parties to the JOA are identified in Appendix Z. Please see Section 2.5 below in this JOA for

information regarding completion of this appendix.

1.3. Jurisdictions, Contacts, Roles, and Responsibilities

This information is provided in Appendices B and C. Section 2.2 below in this JOA describes the

process for completion of these appendices. Please note that there are multiple tabs in these

Microsoft (MS) Excel Workbook appendix files to facilitate use of this information.

1.4. Confidentiality

Given the nature of the work performed by the RAC and the UPIC, information contained within

this JOA is to be shared only with members of the RAC, UPIC, and CMS teams.

1.5. Liability

Although both the RAC and UPIC each individually have a contractual relationship with CMS,

there is no privity of contract between the RAC and the UPIC.

Each contractor will be indemnified and protected by limitations on liability according to the terms

of its respective contract with CMS. In light of the provisions of each contractors current contracts

with CMS and the constraints of law, no amendments to their respective contracts are made through

this JOA with respect to indemnification or limitations on liability.

1.6. Funding

Nothing in this JOA will obligate any parties to perform any tasks that add significant cost and are

outside current scope of work unless adequate funding for these tasks is received from CMS.

2. Document Maintenance

2.1. Standard Core JOA

The Standard Core JOA is established and maintained by CMS to apply standardized best practices

for the interaction between the RAC and UPIC contractors. This Standard Core JOA is purposely

designed so that it does not need to reflect contractor specific information, which is instead

contained in the JOA Appendix Documents. This JOA should not be modified from the standard

without consulting with the TO COTRs.

2.2. JOA Appendices

List of Appendices – Appendix A lists all JOA appendices, identifies the name of the team

responsible for collecting and incorporating updates, and briefly describes how each appendix is to

be created and maintained.

Distributed Update Responsibilities – Appendix documents are separated to facilitate maintenance.

The Contact List, for example, is divided into separate files by team so that each team can make

and distribute updates to their list without having to coordinate input from other teams. If a

contractor holds multiple contracts with CMS and if this contractor wants a separate Contact List

for each contract to facilitate updates by different teams, this is allowed. The multiple tabs within

each Contact List Excel Workbook facilitate differentiation between multiple task orders on a

single contract.

Use Across Multiple JOAs – The templates for these appendix documents, such as the Contact List

templates, have been formatted so that they can be applied to multiple JOAs, eliminating the need

to maintain similar/duplicate information across multiple JOAs.

Document Owner – The name of the individual person on each team who will update each

appendix will be identified by that team at the top of each of their appendix documents. This

facilitates identification of the person to whom updates should be sent.

Templates – CMS provides a standard template for each appendix which can be amended by each

party if necessary to effectively convey the information for their team. To promote consistency,

please apply the standard template to the greatest degree practical.

2.3. Required Roles

To promote proper direction of communication, each RAC and UPIC will

identify, in its Contact List, a Primary and an Alternate for each of the following

Required Roles:

• JOA POC – Joint Operating Agreement Point of Contact – This individual is responsible for

serving as the lead contractor point of contact in establishing and maintaining the JOA content

and in leading the resolution of any JOA-related issues that may arise.

• JOA Approver – One individual from the RAC and one individual from the UPIC

will be identified to approve the JOA.

• Operational Lead – This individual is responsible for serving as the lead point of contact in

performing ongoing operational work under the terms of the JOA. This standard title is used in

the JOA because various teams use different titles for the individuals that they have serving in

this role, and the JOA can not effectively incorporate all of those titles. Each party will identify

their Operational Lead in their Contact List, and they are welcome to add in the Contact List

any other appropriate titles for this individual as well.

2.4. Managing Change

Change Suggestions – Recommendations for updates to JOA documents are encouraged and are to

be sent to the Document Owner.

Revision History – Each Document Owner is to identify changes to JOA documents in the Revision

History Log.

Version Number – The version number is used to make sure that everyone is looking at the same

version of a document. The Document Owner is to increment the JOA version number each time

the JOA is sent out for approval. Multiple updates can be consolidated into the same version

number. The version number is imbedded as the last characters (ex: V01) of each file name.

Process Note: In MS Excel, updates to the version number in the file name are automatically

propagated to the top of each printed Excel document. In MS Word, select “File, Print Preview”

when the version number in the file name is updated to cause the updated version number to be

propagated from the file name to the top of the document.

2.5. Approval of Standard Core JOA

CMS Approval of All Versions of the JOA

• CMS will solicit input, make updates, distribute, and refine this Standard Core JOA as necessary.

Through this cycle of change, CMS will have reviewed and approved all updates.

RAC and UPIC Approval of the First JOA

• CMS directs that all Parties to the JOA (the RAC and UPIC) are to sign (using hand written

signature) the first jointly approved version of the JOA.

• To accomplish this, the JOA Approvers are to hand-write their signature on two copies of

Appendix Z, the JOA Approval Form, which they are then to mail (one copy each) to the

primary RAC JOA POC and UPIC TO COTR who are responsible for their retention and for

providing a copy of these upon request.

• To facilitate communication of status, the JOA Approvers are also to send out an email to these

individuals indicating that they have approved the JOA.

RAC and UPIC Approval of Ongoing Updates

• As CMS makes subsequent updates to the Standard Core JOA, CMS will advise contractors via

Email if the new version is sufficiently changed to require approval. CMS will also update the

last column of the Revision History table of the JOA to keep a record of which versions require

approval.

• A hand written signature is not required for ongoing updates. Instead, an electronic signature

(an electronic copy of the approver’s signature) is to be used as the signature.

• To provide approval for ongoing updates, the JOA Approver is to fill out Appendix Z, paste in

their electronic signature, and then send this completed document via email to the Primary and

Alternate JOA POC for the RAC and UPIC TO COTR. The Primary JOA POCs and TO

COTRs are responsible for retaining these emails and for providing a copy of these upon

request.

No Approval Required on Appendix Updates – No approval is required on updates to the

appendices.

Timing of Approvals – Parties are to provide approval within 10 business days of receipt of an

updated Standard Core JOA. If parties have an issue with the JOA, they are to raise this issue

within 10 business days. If no issues are identified before the end of this period, the JOA updates

will be considered approved.

Distribution – Each JOA POC will disseminate information regarding the update

within their organization.

3. Communication

Communication is a crucial component that will occur at multiple levels using

multiple tools and techniques as described below.

3.1. JOA Checkpoint Meetings

Purpose – These meetings provide a forum for communication on topics of mutual interest among

the Parties to the JOA. Topics will include a discussion of any issues with coordination among the

parties the status of any changes to the JOA documents.

Location – These meetings will most often take place via conference call. In those instances where a

RAC and a UPIC are located close enough to allow a short drive, some participants may join in -

person.

Frequency – The meetings will occur at minimum on a quarterly basis for the first year after the

signing of the first JOA and then at least semi-annually thereafter.

Meeting Dates – CMS representatives need to attend multiple of these meetings across contractors,

so CMS will work with contractors to coordinate spreading of these meetings over time. At the

conclusion of each meeting, the participants will determine mutually agreeable timing (and location

where appropriate) for the next meeting; information that will then be confirmed via email.

Changes will be communicated through the JOA POC via email.

Facilitation – Responsibility for facilitating the meeting will rotate between the RAC and the UPIC.

This will include preparation of the agenda, providing a dial in number, facilitating the discussion,

and capturing and distributing meeting minutes.

Meeting Minutes – Are to be distributed within five business days of the meeting and should clearly

identify Action Items for review in the next meeting.

Participation – Invitees are to minimally include the applicable CMS COTRs and the Primary and

Alternate JOA POC. The JOA POC will invite other participants as appropriate.

3.2. Other Workgroup Meetings

Purpose – In addition to the JOA Checkpoint meetings, the Parties to the JOA will interact on a

regular basis in smaller workgroups to address specific needs.

Location, Timing, and Facilitation –Will be similar to the Checkpoint Meetings.

Formation – Recommendations for new workgroups should be considered at the JOA Checkpoint

Meetings.

3.3. Issue Escalation and Resolution Process

Issues will be escalated if necessary for resolution via the following process:

1. Source – The RAC and the UPIC individuals identifying the issue will work with their

counter-parts first to attempt to resolve the issue.

2. JOA POCs – If they are unable to come to a resolution, the matter will be brought to the

attention of the RAC Contractor JOA POC and the UPIC JOA POC (identified in the

Contractor Contact List Appendices).

3. Operational Leads – If they are unable to come to a resolution, the matter will be

escalated to the RAC Operational Lead and the UPIC Operational Lead (identified in the

Contractor Contact List Appendices).

4. CMS Contract Officer Technical Representatives (COTRs) – If they are unable to come

to a resolution, the Operational Leads will bring the matter to the attention of the CMS

COTRs (identified in the CMS Contact List Appendices).

5. JOA Alternative Dispute Resolution (ADR) Team – In the event the dispute between the

RAC and the UPIC cannot be resolved, the issues will be directed in writing to the CMS

RAC and UPIC Contracting Officers, Project Officers, and COTRs for resolution by the

JOA ADR) team. The ADR team will issue a written determination to both the RAC and

the UPIC.

Timing of Issue Escalation and Resolution – The speed with which issues are escalated and

resolved will be dependent on the priority of the issue, with higher impact issues receiving quicker

attention by all parties. As a general guideline, parties should endeavor to resolve or escalate an

issue within 1-3 days of its receipt, or they should reply to all parties to advise them of the reasons

for additional time needed for action.

3.4. Non-Compliance

If a party does not comply with a provision of the JOA, notification and resolution will take place

as follows:

1. Notification – If a party does not comply with a provision of the JOA, the Operational

Lead for that party will notify the Operational lead for the other party.

2. Resolution – A non-compliance is often one-time event with no significant impact

which can often be quickly resolved and prevented in the future through the interaction

of the Operational Leads. In these circumstances, escalation is not required.

3. Escalation – If a non-compliance creates an impact that either party feels requires

escalation either for notification purposes or for issue resolution purposes, then the

Operational Leads will notify the CMS COTRs. If necessary, the ADR process

described above will be applied to achieve closure.

3.5. Communication Regarding CMS Changes

As part of ongoing operations, the RAC and the UPIC Contractor staff will both review documents

received from CMS, including Transmittals, Program Memoranda, Change Requests and Notes.

The RAC and the UPIC Contractor will continue to determine their own operational impact and

will provide comments and escalate issues to CMS independently, as appropriate.

All issues that are determined to have an impact on any RAC or UPIC Contractor operations

included in this JOA will be submitted to the RAC and UPIC JOA POCs for discussion at the next

JOA Checkpoint Meeting, or sooner if appropriate.

3.6. Securing Email Information

CMS has indicated that it is not appropriate to send emails containing beneficiary or provider

identifiers (including names and numbers) even if those identifiers are contained within a password-protected attachment. Each JOA Participant is responsible for obtaining, understanding,

interpreting, and implementing its own policies and procedures regarding use of email containing

beneficiary or provider identifiers. CMS Secure Email may be used to send protected information

to CMS and other users of this email system. If Secure Email is not available, send this information

via an encrypted CD through registered mail.

4. Identification and Action on Fraudulent Behavior

4.1. Identification and Notification of Fraud by the RAC

RAC Responsibility – When the RAC encounters an issue that meets the criteria of potential fraud,

the RAC will notify the RAC PO who will forward this to the Director of the Division of Benefit

Integrity Management Operations.

Indicators of Fraud – The following are indicators of fraud that must be reported to the RAC PO. The

RAC should use their best judgment to determine if other findings may constitute fraudulent

behavior. Section 6.2 of this Standard Core JOA provides information regarding training for the RAC

staff to identify fraud.

• Submission of false claims

• Services being rendered by unlicensed individuals

• Ordered services being provided without a legitimate physician order

• Claims for beneficiaries or providers that are deceased

• Non-compliance with medical record requests

4.2. Coordination with Law Enforcement

The UPIC will interact with Law Enforcement related to potential fraudulent activity. The RAC

must not contact Law Enforcement with fraud suspicions; they must contact the RAC PO. Law

enforcement may contact the RAC with recovery inquiries but any other LE RFIs shall be referred

by the RAC directly to the UPIC.

4.3. High Risk Areas

CMS may identify High Risk areas within a UPIC jurisdiction. These are areas that are known to

have wide-spread fraud. The UPICs are required to take aggressive, rapid and innovative measures

to curtail fraud in these areas and this may impact the RAC’s ability to perform audits in these

areas. The UPIC will have the ability, in High Risk Areas, to suppress providers in order to protect

the UPIC and Law Enforcement’s ability to identify, prevent and prosecute fraudulent activities.

5. Training

5.1. Training provided by the UPIC

Purpose – Fraud detection and awareness training will be provided to assist the RAC in identifying

fraudulent behavior, including indicators that RAC staff should look for and examples of real fraud

scenarios.

Audience – This training is designed for members of the RAC team.

Initial and Annual Training – The UPIC will provide this training at the start of working together as

contractors and on at least an annual basis thereafter.

New Employee Training – The RAC will be responsible to provide this on-going training for new

RAC employees throughout the year using the materials provided by the UPIC.

Participation Requirement – Training participation is required to at least one session per year to be

provided by the UPIC. UPICs can rotate the responsibility for training and must avoid duplication

across contracts.

Training on Changes – Additional training will be provided by the UPIC when substantive changes

are identified in fraud detection and awareness.

Exhibit 44.1

(Rev. 902, Issued: 09-27-19, Effective: 10-28-19, Implementation: 10-28-19)

Revision History

Version Date Changed By Description of Change Signature Required

Joint Operating Agreement

Between

XXX

In its capacity as the Supplemental Medical Review

Contractor (SMRC)

And

XXX

In its capacity as the Unified Program

Integrity Contractor XXX

Prepared by:

XXX

Table of Contents

Revision History .......................................................................................................................... 246

Table of Contents ........................................................................................................................ 248

1. Introduction ............................................................................................................................. 250

1.1 Purpose of the Supplemental Medical Review Contractor ............................................... 250

1.2 Purpose of the SMRC Joint Operating Agreement ........................................................... 250

1.3 Scope ................................................................................................................................. 250

1.4 Joint Operating Agreement Participants and Roles........................................................... 250

1.4.1 Supplemental Medical Review Contractor’s Role ..................................................... 251

1.4.2 Unified Program Integrity Contractor’s Role............................................................. 251

1.4.3 Centers for Medicare & Medicaid Services’ Role ..................................................... 252

1.5 Liability ............................................................................................................................. 252

1.6 Mutual Confidentiality ...................................................................................................... 252

1.7 Independent Contractors ................................................................................................... 253

1.8 Privacy ............................................................................................................................... 253

1.9 Funding.............................................................................................................................. 253

2. Communication ....................................................................................................................... 253

2.1 Contact Information .......................................................................................................... 253

2.2 Point of Contact Roles....................................................................................................... 253

2.3 Joint Operating Agreement Meetings ................................. Error! Bookmark not defined.

2.4 Workgroup Meetings........................................................... Error! Bookmark not defined.

2.5 Maintenance of the JOA .................................................................................................... 255

2.6 Dispute Resolution Process ............................................................................................... 255

2.7 Mailing Information .......................................................................................................... 256

3. Systems.................................................................................................................................... 256

3.1 Data Files........................................................................................................................... 256

3.2 Security.............................................................................................................................. 256

4. Processes ................................................................................................................................. 256

4.1 Misdirected Communications ........................................................................................... 256

4.2 Ad Hoc Reports ................................................................................................................. 257

4.3 Fraud Referral ................................................................................................................... 257

4.4 Process Improvement ........................................................................................................ 257

Appendix A. Master Contact List ............................................................................................... 258

Table A-1. Supplemental Medical Review Contractor ............. Error! Bookmark not defined.

Table A-2. Unified Program Integrity Contractor xxx ............................................................ 258

Table A-3. Centers for Medicare & Medicaid Services .......................................................... 258

Appendix B. JOA Approval Signature Form .............................................................................. 258

1. Introduction

1.1-Purpose of the Supplemental Medical Review Contractor

The purpose of the SMRC is to perform and/or provide support for a variety of tasks aimed at

lowering the improper payment rates and increasing efficiencies of the Medical Review (MR)

functions primarily for Medicare Fee-for-Service (FFS); other product line analysis is limited and

may include Medicaid FFS, private and group health insurance lines of business and Prescription

Drug Plan (Part D). One of the primary tasks will be conducting large volumes of nationwide MR

as directed by the Centers for Medicare & Medicaid Services (CMS). The MR will be performed on

Medicare FFS claims for Part A, Part B, and DMEPOS programs. These medical review activities

will assess compliance with Medicare’s coding, coverage, billing, and payment requirements and

identify claims improperly paid. The SMRC will recommend recoupment and/or adjustment for

claims identified as improperly paid. Having a centralized MR resource that can perform large

volume of MR nationally shall allow for a timely and consistent execution of MR review, activities,

and decisions. The SMRC shall select subject claims, perform research and/or data analysis, and

conduct reviews in a manner that will minimize provider and supplier burden.

1.2-Purpose of the SMRC Joint Operating Agreement

The purpose of this no-cost Agreement is to set forth the terms and conditions pursuant to which the

Parties will coordinate efforts to maintain consistency of the Medicare program in accordance with

the provisions of their respective CMS contract (“CMS Contract”). The term of this Agreement

shall commence on the Effective Date and continue until either Party’s CMS Contract expires, or it

is terminated by either Party upon thirty (30) days written notice to the other Party.

1.3-Scope

This Agreement is intended to serve as a framework for the collaborative measures the Parties will

take to implement, maintain, and advance their mutually shared goal of preserving the integrity of

the Medicare program; it is not intended to be a comprehensive description of the Parties’ working

relationship. This Agreement does not create any affirmative duties, rights or legal obligations

between the Parties, nor does it give any person or entity their successors and permitted assigns,

any right, remedy or claim in it. Each Party has a contractual relationship with CMS and each

party shall be solely responsible to CMS for its performance under this JOA and the terms of this

Agreement shall not alter or amend a Party’s CMS Contract. If there are any conflicts between the

terms of this Agreement and a Party’s CMS Contract, the terms of the Party’s CMS Contract shall

take precedence. The terms of this Agreement shall be interpreted so as to resolve any conflict

between it and a Party’s CMS Contract, and, if necessary, this Agreement shall be amended to

reconcile any unresolved conflict with a Party’s CMS Contract.

1.4-Joint Operating Agreement Participants and Roles

The term “JOA Participants” refers to the SMRC, CMS, and Unified Program Integrity Contractor

(UPIC).

1.4.1-Supplemental Medical Review Contractor’s Role

The SMRC will perform research and analysis, MR, statistical sampling, and extrapolation. The

SMRC will specifically include the following activities:

• Perform Medicare Part A and Part B (including DME) post payment MR in accordance with

CMS instructions including expedited reviews. The list of providers will be sent via secure

email provided in Section 4.3;

• For post payment medical review, develop and send a letter for the solicitation of medical

records and supporting documentation needed to support the claims, when necessary;

• Perform claim re-reviews for claims reviewed initially by the SMRC;

• Perform statistical sampling and extrapolation to assess overpayment or potential

overpayment(s) made on claims;

• Access the Recovery Auditor Data Warehouse (RDW) prior to selecting claims for review

to ensure they are not excluded or suppressed;

• Upload all claim samples identified into the RDW;

• Review all services in accordance with the applicable statutes, CMS guidelines, and

coverage requirements;

• Recommend claim denial for any claim when a provider fails to send medical records or

supporting documentation;

• Maintain a tracking system to reflect and identify MR activities for all claims;

• Ensure coordination of efforts and prevent duplication of activities or interference with an

existing investigation or corrective action plan;

• Ensure each MR is conducted by a Registered Nurse (RN);

• Ensure each coding review is conducted by a Certified Professional Coder (CPC) or

Certified Coding Specialist (CCS) with an active certification;

• Ensure records are maintained confidentially in accordance with the Statement of Work

(SOW) and applicable regulations;

• Participate in Administrative Law Judge (ALJ) hearings as a participant or party, as

appropriate, to defend positions or provide testimony;

• Provide education on eligible claims to providers as requested for those claims reviewed by

SMRC; and

• Participate in discussion periods with providers as requested for those claims reviewed by

SMRC that are eligible for Discussion & Education (D&E).

The SMRC does not have responsibility for:

• Claims processing and adjudication activities;

• Performing redeterminations related to appealed initial determinations conducted by the

SMRC; and

• Cost report audit activities.

1.4.2-Unified Program Integrity Contractor’s Role

The UPICs role and responsibilities include:

• Fraud, waste and abuse investigations and program integrity related data analysis; and

• Pre and post payment claim review for program integrity purposes.

1.4.3-Centers for Medicare & Medicaid Services’ Role

CMS’ Contracting Officers’ Representative (COR), Contract Specialist, and Contracting Officer

have overall responsibility for the SMRC. The Contract Specialist and Contracting Officer, Office

of Acquisitions and Grants Management (OAGM), in coordination with the COR, are the only

persons authorized to:

• Enter into and commit or bind the government by contract for supplies and services;

• Accept nonconforming work or waive any requirement of the contracts;

• Authorize reimbursement to the contractor for any costs incurred during the performance of

the contract; and

• Modify any term or condition of the contract (that is, make any changes in the SOW,

modify or extend the period of performance, change the delivery schedule).

1.5-Liability

Each Party is indemnified and protected by limitations on liability according to the terms of its

respective contract with CMS.

Except with respect to a breach of the confidentiality provision set forth in section 1.6 below, titled

“Mutual Confidentiality”, this JOA shall not be construed to give rise to any binding obligation,

rights, duty or liability, of any kind whatsoever, of any Party to this JOA to any other party.

1.6-Mutual Confidentiality

The parties understand, acknowledge and agree that each party’s inventions, discoveries,

proprietary information and trade secrets are of critical importance to its ongoing operations and

prospects. During the course of performing services for CMS according to their respective

contracts, described above, the parties will likely have access to information that is confidential and

proprietary to the other party. In addition, each party may create inventions, make discoveries,

write software or code, develop file layouts, methodologies or processes, and create applications

during the course of the parties’ relationship.

Examples of proprietary information and trade secrets include, but are not limited to, discoveries,

improvements, processes, developments, designs, know-how, data, file layouts, documentation,

computer programs (including but not limited to all source code for those programs) and formulae.

Each Party agrees to hold the other party’s Confidential Information to at least the same level of

protection against unauthorized disclosure or use as the receiving party normally uses to protect its

own information of a similar character, but in no event less than reasonable care.

Neither party shall disclose to any person in any manner, either before, during or after the term of

this JOA, proprietary or trade secret information (as hereafter defined) except to the extent

necessary for the performance of each party’s duties under this JOA, or as required by CMS

pursuant to each party’s contract with CMS, as applicable. Each party shall not use

proprietary/trade secret information of the other for any other purpose whatsoever. Each party

agrees to cooperate with the other party, and to use its best efforts, to prevent the unauthorized

disclosure, use or reproduction of any proprietary/trade secret information of the other.

Nothing in this Agreement shall prohibit or limit a party’s use of information (including, but not

limited to, ideas, concepts, know-how, techniques, and methodologies) (i) previously known to that

party, prior to its receipt from the disclosing party, (ii) independently developed without use of the

Confidential Information, (iii) acquired by it from a third party which was not, to the recipient's

knowledge, under an obligation to the disclosing party not to disclose such information, or (iv)

which is or becomes publicly available through no breach of this Agreement by the receiving party.

The obligation to protect Confidential Information shall survive the expiration or termination of this

JOA.

1.7-Independent Contractors

The parties each recognize and agree that they are independent contractors. There is no privity of

contract between these Parties. Nothing contained in this Agreement shall be construed to make any

party an agent, servant, partner, employee of or joint venture of or with any other party. No party

has the right or authority to interfere with or in any manner influence, direct or control the decision-making process, evaluations, judgments or reviews of any other. No party shall have any right or

authority, whether express or implied, to assume or create any obligation, duty, or responsibility

whatsoever on behalf of any other party.

1.8-Privacy

The parties agree that issues pertaining to the Privacy Act of 1974, and the Health Insurance

Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable

Health Information (The Privacy Rule) published in April 2003 are covered by the two

organizations’ independent contracts with CMS.

When future privacy regulations are published, the two organizations will review that information

and address any impact to joint processes in subsequent versions of the JOA. The parties agree that

issues pertaining to the confidentiality, privacy, and security of Medicare data are covered by the

two independent contracts with CMS.

1.9 Funding

Nothing in this JOA will obligate either party to perform any tasks that are outside the current scope

of work, unless CMS directs such tasks and provides adequate funding.

2. Communication

2.1-Contact Information

Contact information for all parties is provided in Appendix A, Master Contact List.

2.2-Point of Contact Roles

To ensure that communication is properly directed, CMS, the UPIC and the SMRC will identify (in

Appendix A, Master Contact List) representative(s) to serve as:

• JOA Point of Contact (POC): Each party will designate a representative responsible for

serving as the lead company/agency POC in establishing and maintaining the JOA content,

and in leading resolution of any JOA-related issues that may arise. Additional information

regarding maintenance of the JOA is included in Section 2.5, Maintenance of the JOA.

• JOA Signatory: Each party will designate a representative who is responsible for providing

final approval and signature for updates to the JOA.

• Information Technology (IT) POC: Each party will designate a representative to act as a

focal point for the exchange of information relevant to systems configuration, operation, and

communications.

2.3-Joint Operating Agreement Meetings

The SMRC and UPIC will assess for and discuss any JOA updates during the monthly workgroup

meetings. The SMRC and UPIC JOA meetings will provide a forum for communication among the

SMRC and UPIC JOA participants. The SMRC COR and the UPIC COR are to be notified of all

SMRC and UPIC JOA conference calls since they are optional participants.

2.4-Workgroup Meetings

Workgroups will be formed based on input from JOA Participants to provide focused attention on

key topics. Changes in participants in the workgroups will not necessitate a change in the JOA.

These workgroup meetings will take place by conference calls.

SMRC and UPIC Coordination Workgroup: On an ongoing basis, this workgroup will meet at least

monthly on the same date/time each month to facilitate coordination of activities related, but not

limited to, workload, re-reviews, discussion and education sessions, overpayments and appeals. In

addition to this workgroup, representatives may interact, as needed, in smaller workgroups to focus

on specific areas, such as overpayments and appeals.

Additional Meetings: The SMRC and UPIC JOA POC will schedule additional conference calls as

requested by the JOA Participants.

Agenda: The SMRC JOA POC will distribute the Agenda to all members by e-mail in advance of

the next meeting. The SMRC JOA POC will solicit Agenda items from SMRC and UPIC JOA

participants approximately one week prior to the meeting. The meetings may include (along with

other agenda items) high-level data analysis findings, statistical reports, recommendations, review

activities, and action items.

Participation: Workgroup participation will include representation from CMS, the UPIC, and

SMRC. At minimum, JOA Participants will include the UPIC Operations, UPIC JOA POC, SMRC

Program Manager (PM), SMRC JOA POC, CMS SMRC COR/ACOR/BFL, and CMS UPIC

COR/ACOR/BFLs and others as applicable.

JOA Improvements: Continuous improvement of the JOA will be an agenda item for discussion at

each meeting. Additional information regarding initiating and controlling changes to the JOA is

described in Section 2.5, Maintenance of the JOA.

Minutes: SMRC will take Minutes during each workgroup meeting and distribute them by

e-mail to all participants within ten business days of the meeting. SMRC will also track all action

items in the minutes and report on them at each workgroup meeting.

2.5-Maintenance of the JOA

JOA POCs are invited to initiate continuous improvements to the JOA. Any such suggestions will

be discussed at the next regularly scheduled JOA meeting or through special sessions as necessary.

Change Suggestions: All suggestions are to be sent to the SMRC JOA POC. Within seven business

days, the SMRC JOA POC will distribute a draft to CMS and the UPIC JOA POCs. Feedback is to

be provided within seven business days. The SMRC JOA POC will then distribute a final draft to

CMS and the UPIC JOA POC. If no issues are identified within seven business days, the updates

will be considered accepted. The SMRC JOA POC will disseminate information regarding the

updates to CMS and the UPIC JOA POC annual reviews, 14 business days will be allowed to

review changes and make updates for the annual JOA reviews.

Tracking Changes: Changes to the JOA are identified in the Change History Log on the second

page of this document and are controlled by a version number in the upper right corner of each page

of the document. Changes to the appendices to this document are also controlled by a version

number in the lower left corner of each appendix.

Signature of JOA: For those changes to the body of the JOA that are determined by the SMRC

CMS COR and BFLs to be significant (as identified in the Change History Log on the second page

of this document), new approvals will be collected. Approvals are not necessary for changes to the

appendices (such as the Appendix A, Master Contact List). Approval of the first JOA will adhere to

the following procedure: All parties to the JOA are to sign the first jointly approved version of the

JOA and subsequent changes using Appendix B, Joint Operating Agreement Approval Signature

Form. Such signed documents will be distributed to the relevant POCs for the parties identified in

Appendix A, Master Contact List.

2.6-Dispute Resolution Process

Disputes/issues will be escalated, if necessary, for resolution by the following process:

1. The SMRC and the UPIC counterparts will first attempt to resolve the issue.

2. If the SMRC and the UPIC counterparts are unable to come to a resolution, the matter will

be brought to the attention of the SMRC JOA POC and the UPIC JOA POC (as identified in

Appendix A, Master Contact List).

3. If the SMRC JOA POC and the UPIC JOA POC are unable to come to a resolution, the

matter will be escalated to the SMRC PM and the UPIC Project Manager (as identified in

Appendix A, Master Contact List).

4. If the SMRC PM and the UPIC Project Manager are unable to come to a resolution, the

SMRC PM will bring this matter to the attention of the SMRC CMS COR and the UPIC

Project Manager will bring this matter to the attention of the UPIC CMS COR (as identified

in Appendix A, Master Contact List).

5. If the dispute between the SMRC and the UPIC cannot be resolved, the issues will be

directed, in writing, to the CMS CORs and BFLs for resolution by a JOA Alternative

Dispute Resolution Team.

2.7-Mailing Information

All information mailed between the UPIC and SMRC will be sent by delivery service (FedEx®,

United Parcel Service of America [UPS®], or DHL Worldwide Express [DHL®]) and shipped to

the addresses specified below:

UPIC Company Name

Attn: Department

Mailing Address

City, State Zip Code

The sender will e-mail the intended recipient a confirmation e-mail containing an inventory of the

shipment contents, encryption information (if applicable), and tracking number of the package. The

recipient will confirm receipt of the package upon arrival. Refer to Section 3.2, Systems, regarding

security.

3. Systems

3.1-Data Files

The CMS has directed the SMRC to perform data analysis activities to support MR and

overpayment extrapolation. These activities will require the SMRC to obtain data from various

resources, including, but not limited to, CMS’ One Program Integrity (One PI) Shared Systems

database, CMS’ National Claims History (NCH) database, and RDW. If data is needed from the

UPICs, this will be discussed during the workgroup meeting.

3.2-Security

Each party agrees to adhere to the security requirements in the Business Partner System Security

Manual (BPSSM). Both parties agree to work together on all aspects of security in the BPSSM, or

as otherwise issued via Technical Direction Letter or other means by CMS, that require the joint

cooperation of both parties. Mail and email exchanges containing Personally Identifiable

Information (PII) will follow the requirements as outlined by the most current version of the ARS

which states the PII must be secured in an attachment that has been zipped using FIPS 140-2

validated software (i.e. SecureZip). Each party further agrees to adhere to CMS JSM/TDL-09323

and CMS JSM/TDL-11141: Guidelines for Implementing the Centers for Medicare & Medicaid

Services’ (CMS) Revised Information Security Incident Handling and Breach Analysis/Notification

Procedures.

4. Processes

4.1-Misdirected Communications

Misdirected communications may include written, e-mail, or facsimile inquiries received from

providers. Unless otherwise addressed in this JOA, any misdirected communications will be

forwarded to the appropriate party (SMRC or UPIC) following the process outlined in Section 2.7

Mailing Information.

4.2-Collaboration

The SMRC will send the UPIC file of providers/suppliers on review via email at xxxx@xxxxxx.xx

4.3-Ad Hoc Reports

Ad hoc reports may be requested by either the UPIC or SMRC via the Ad Hoc Request Form

(Appendix C xxx). The completed form must be faxed or emailed to the appropriate JOA POC. All

requests will be evaluated by the receiving contractor for approval based upon feasibility and cost

of implementation. The receiving contractor may directly contact the requesting individual to

clarify data requests as needed. The SMRC and UPIC JOA POCs or authorized individual will

coordinate with the requestor when these reports are available.

4.4-Fraud Referral

The SMRC will document their findings in a standard format, and, when appropriate, refer the case

to the Center for Program Integrity (CPI)/Unified Program Integrity Contractor (UPIC) for

development through the current process in place with CMS. The SMRC will remain accessible to

the referral agency to facilitate their investigation, and to prepare potential cases for litigation or

prosecution. SMRC referrals to UPIC xx of potential fraudulent activities should be sent to the

UPIC xx at: UPICxxLead@admedcorp.com

4.5-Process Improvement

Where appropriate and feasible, the parties will provide recommendations on process refinements.

Such changes will be presented and approved through the process described in Section 2.5

regarding changes to the JOA.

Appendix A. Master Contact List

Table A-1. Supplemental Medical Review Contractor

POC Role Representative Contact Number E-mail

JOA POC

Project Manager

MR Director

Information Security

Manager

MR Manager

Operations Manager

Liaison, Hearing & Appeals

Coordinator

Table A-2. Unified Program Integrity Contractor xx

POC Role Representative Contact Number E-mail

UPIC JOA POC

UPIC Operations POC

UPIC Appeals Manager

UPIC Appeals Manager

UPIC Overpayment team

leader—Audit

UPIC Overpayment team

Leader—Recoupment

UPIC POE Manager

JOA Signatory

JOA Signatory

Table A-3. Centers for Medicare & Medicaid Services

SMRC COR

SMRC ACOR/BFL

Contracting Officer

Contracting Specialist

Appendix B. JOA Approval Signature Form

Company/Entity Name:

Signatory Name (Printed):

Signatory Signature: ______________________________________________

Date: ____/____/____

Company/Entity Name:

Signatory Name (Printed):

Signatory Signature: ______________________________________________

Date: ____/____/____

Company/Entity Name:

Signatory Name (Printed):

Signatory Signature: ______________________________________________

Date: ____/____/____

Exhibit 45 – UPIC Prepayment and Postpayment Notification Letter

(Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20)

DATE: UPIC NAME/JURISDICTION:

PROVIDER NAME: UPIC CONTACT/PHONE NUMBER:

PROVIDER ADDRESS: UPIC ADDRESS:

PROVIER NUMBER:

Dear Provider Name:

As a Medicare contractor, the Unified Program Integrity Contractor (UPIC) is required by the

Centers for Medicare & Medicaid Services (CMS) to analyze claims payment data in order to

identify areas with the greatest risk of inappropriate program payment. Specifically, as a (indicate

UPIC), (write UPIC Name) is required to investigate situations of potential fraud, waste, and abuse.

Your claims have been selected for a comprehensive medical review of your billing for Medicare

services pursuant to CMS’ statutory and regulatory authority. You were selected for this review

because our analysis of your billing data indicates that there may be aberrancies in your billing.

We have selected claims for services provided during the period through . You will

subsequently receive a request for medical records, which will explain the specific documentation

that is being requested. If you have any questions regarding the letter requesting medical

records/documentation, please contact (UPIC Contact’s Name) at (Phone Number of UPIC

Contact).

Thank you for your prompt response to the request for medical records/documentation.

Exhibit 46.1 - MAC Unified Postpayment ADR Sample Letter

(Rev.557, Issued: 11-26-14, Effective: 12-29-14, Implementation: 12-29-14)

Date:

Reference ID:

Attention:

Address:

NPI:

PTAN:

Phone:

Fax:

Request Type & Purpose: Notification of Post-payment Probe Review and Request for Medical Records

Subject: Additional Documentation Required

Dear Medicare Provider/Supplier,

The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce improper

payment of Medicare claims1. As part of our effort to accomplish this goal, the Medicare

Administrative Contractor (MAC) program will conduct a post-payment medical review of selected

Medicare Part A claims.

Reason for Selection

As an A/B MAC, 'Review Contractor Name' is tasked with preventing inappropriate Medicare

payments. This is accomplished through provider education, training, and the medical review of

claims. 'Review Contractor Name' recently completed review of a sample of service-specific

claims for HIPPS code XXXXX (1st or 2nd episode with 11 to 13 therapy visits). The calculated

charge denial rate (CDR) for these claims was 100%. Refer to the enclosed Encrypted CD for the

complete list of claims and denial reasons.

Action: Additional Documentation

Federal law requires that providers/suppliers submit medical record documentation to support

claims for Medicare services upon request. Providers/suppliers are required to send supporting

medical records to the MAC program. Providing medical records of Medicare patients to the

MAC program does not violate the Health Insurance Portability and Accountability Act (HIPAA).

Patient authorization is not required to respond to this request.

Case ID: 1212121

Patient

Name

Date of

Birth

HIC

Number

Date of

Service

Rendering Provider /

Supplier

Claim

ID

Procedure

Code

When: mm/dd/yyyy

Please provide the requested documentation by mm/dd/yyyy. A response is still required by

mm/dd/yyyy even if you are unable to locate the requested information.

When the review is completed, you will be notified of the results. The CMS’ goal is to complete

the review and deliver the results to providers/suppliers within 60 days of the receipt of all

medical records needed for the review.

1 Social Security Act Sections 1833(e), 1815(a), and 1842(p)(4)

Consequences

If the provider/supplier fails to send the requested documentation or contact CMS by

mm/dd/yyyy, the provider’s/supplier’s Medicare contractor will initiate claims adjustments or

overpayment recoupment actions for these undocumented services.

Instructions

The documentation submitted for this review must be a copy of the patient’s medical record for each

encounter clearly identified for each requested beneficiary and the date of service. Providers/suppliers are

responsible for obtaining supporting documentation from third parties (hospitals, nursing homes, suppliers,

etc.).

• Refer to the ‘Supporting Documentation’ attachment for a list of required supporting documentation

to be submitted.

• Providers/suppliers must pay the cost of providing this documentation; it cannot be billed to CMS or

the MAC program.

• The CMS encourages providers/suppliers to respond quickly.

• Please do not include Powers of Attorney, Living Wills, or Correspondence.

• During this review period and at all times, in order to receive payment, providers/suppliers must

continue to submit claims for all services performed on a beneficiary.

Submission Methods

Providers/Suppliers may submit this documentation in any of the following ways:

Via postal mail or Encrypted CD/DVD:

1. Include a copy of the Post Pay request letter with your documents.

2. Complete the ADR Response Cover Sheet Form (enclosed) and place on top of the entire set

of documents to be submitted.

a. An image of the coversheet may be included with the CD/DVD or may be scanned

as the first image seen within your CD/DVD.

3. When submitting responses for multiple claims, please make a copy of the enclosed Part A

Post Pay ADR Response Separator Sheet and insert between the responses for each

Document Control Number (DCN).

4. If the CD/DVD is password protected, send an email to John.Doe@Company.com and

Jane.Doe@Company.com and include the package tracking number and password.

5. Mail to the following:

Regular Mail: Overnight Mail:

Company Name Company Name

Medical Review Medical Review

Mail Code XXXX OR Mail Code XXXX

Post Office Box XXXXX Street Address

City, State Zip Code City, State Zip Code

Via fax to:

1. XXX-XXX-XXXX

2. Include a copy of the ADR letter with your documents.

3. Complete the ADR Response Cover Sheet Form (enclosed) and place on top of the entire set

of documents to be faxed.

4. When submitting Post Pay ADR responses with multiple claims, make a copy of the

enclosed Post Pay ADR Response Separator Sheet and insert between the responses for each

Document Control Number (DCN).

Via Electronic Submission of Medical Documentation (esMD):

1. Include a copy of the Post Pay request letter with your documents.

2. Complete the ADR Response Cover Sheet Form (enclosed) and place on top of the entire set

of documents to be sent.

3. When submitting Post Pay ADR responses with multiple claims, make a copy of the

enclosed Post Pay ADR Response Separator Sheet and insert between the responses for each

Document Control Number (DCN).

4. Convert all documents, including your cover sheets, to PDF.

5. Submit your documentation to your CONNECT-compatible gateway or HIH.

6. More information on esMD can be found at www.cms.gov/esMD

Questions

If you have any questions please contact XXXXXXXX at XXX-XXX-XXXX or via postal mail at

the following:

Company Name

Street Address

City, State Zip Code

Sincerely,

A/B MAC Jurisdiction X Medical Review

Attachments / Supplementary Information

1. Encrypted CD with a listing of claims requiring medical documentation

2. Supporting Documentation Required List

3. ADR Response Cover Sheet Form

4. Separator Sheet Form

Exhibit 46.2 - DME MAC Unified Post-Payment ADR Sample Letter

(Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19)

Letter Date:

Provider/Supplier Name

Provider/Supplier

Address City, State Zip

Case ID #:

NPI /Provider #:

PTAN:

Request Type & Purpose: New Request, Post-Payment Claim Review

Subject: Additional Documentation Required

Dear Medicare Provider/Supplier,

The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce improper

payment of Medicare claims1. As part of our effort to accomplish this goal, the Medicare

Administrative Contractor (MAC) program will conduct a post-payment medical review of

selected Medicare DME claims.

Reason for Selection

In the xx quarter 20XX, “Supplier’s Name” HCPCS code XXXXX claim volume was two or

more standard deviations above the norm when compared to all suppliers billing HCPCS code

XXXXX in Jurisdiction X. This high claim volume billed by a new supplier for a high dollar

item is of concern to the DME MAC.

When services appear outside the norm, the DME MAC must verify whether the potential

error(s) represent an unacceptable practice. The DME MAC is validating this concern by

performing a post-payment review on ## randomly selected claims billed by “Supplier’s Name”.

ACTION: MEDICAL RECORDS REQUIRED

Federal law requires that providers/suppliers submit medical record documentation to support

claims for Medicare services upon request. The Centers for Medicare & Medicaid Services DME

MAC program has randomly selected one or more of your Medicare claims for review, and

providers/suppliers are required to send supporting medical records when requested. Providing

medical records of Medicare patients to the MAC program does not violate the Health Insurance

Portability and Accountability Act (HIPAA). Patient authorization is not required to respond to

this request. Please refer to the Instructions Section below for a list of supporting documentation

required.

1Social Security Act Sections 1833 [42 USC 1320c-5 (a) (3)]

Case ID: XXXXXXX

Patient Name MBI Date of Service Claim ID Procedure Code

When: MM/DD/YYYY

Please provide the requested documentation by mm/dd/yyyy. A response is still required by

mm/dd/yyyy even if you are unable to locate the requested information.

Consequences

If the provider/supplier fails to send the requested documentation or contact CMS by

mm/dd/yyyy, the provider’s/supplier’s Medicare contractor will initiate claims adjustments or

overpayment recoupment actions for these undocumented services.

Instructions

• Submit supporting documentation from third parties (hospitals, nursing homes, suppliers etc.).

Providers/suppliers are responsible for obtaining and providing the following documentation:

o Physician’s notes within 30 days of initial date: mm/dd/yyyy

o Diagnostic Tests

• Submit the bar coded cover sheet with your submission (optional)

• Providers/suppliers must pay the cost of providing this documentation; it cannot be billed to

CMS.

Submission Methods

Providers/suppliers may submit this documentation in any of the following ways:

• Via postal mail to:

Company Name

Company Address

City, State Zip Code

• Via fax to: XXX-XXX-XXXX

• Via Electronic Submission of Medical Documentation (esMD):

- More information on esMD can be found at www.cms.gov/esMD

- When sending records via esMD, please include a CASE ID number in your file

transmission

• Via Encrypted CD: See attachment for detailed instructions.

Questions

If you have any questions, please contact:

Contact Name

Department

Company Name

Contact Address

City, State Zip

Code

Office: XXX-XXX-XXXX

Toll Free: XXX-XXX-XXXX Fax: XXX-XXX-XXXX

Company Email

Address

Company Website

Sincerely,

DME MAC Jurisdiction X Medical Review

Attachments / Supplementary Information

1. Important Notices

2. Cover Sheet

3. Change of address information

4. Appeals process

5. Comparative Data

6. Encrypted CD Submission Process

Exhibit 46.3 – Recovery Audit Contractor (RAC) Unified Postpayment ADR

Sample Letter

(Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19)

Region X

RAC

Date:

Reference ID:

Attention:

Address:

NPI:

PTAN:

Phone:

Fax:

Request Type & Purpose: Additional Documentation Required and Request for Medical

Records

Dear Medicare Provider/Supplier,

The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce the

improper payment of Medicare claims8 The Recovery Audit Program, mandated by Congress

has been developed to assist in accomplishing this goal.

Reason for Selection:

Your RAC, (insert name of RAC), is requesting additional documentation for the selected list of

claims as part of a post-payment complex review approved by CMS. Providers/suppliers will

receive a Review Results Letter after a claim determination has been made. If an improper

payment (underpayment or overpayment) is identified, these claims will be sent to your

Medicare Administrative Contractor (MAC) for adjustment.

Please refer to the enclosed Claims Selected for Review Spreadsheet for a list of selected

claims.

Action: Additional Documentation

Federal law requires that providers/suppliers submit medical record documentation to

support claims for Medicare services upon request. Providers/suppliers are required to send

supporting medical records to (insert RAC name). Providing medical records of Medicare

Recovery Auditor

logo

patients to (insert RAC name) does not violate the Health Insurance Portability and

Accountability Act (HIPAA). Patient authorization is not required to respond to this request.

When: mm/dd/yyyy

Please provide the requested documentation by mm/dd/yyyy. A response is still required

by mm/dd/yyyy even if you are unable to locate the requested information.

When the review is complete, you will be notified of the results. (Insert RAC name)’s goal is

to complete the review and deliver the results to providers/suppliers within 30 days of receipt

of all medical records needed for the review.

Consequences

If the provider/supplier fails to send the requested documentation to (insert RAC’s name) by

mm/dd/yyyy, the provider’s/supplier’s MAC will initiate claims adjustments or overpayment

recoupment actions for these undocumented services.

Instructions

1. The documentation submitted for this review must be a copy. Do not submit

original documentation.

2. A copy of this additional documentation request letter should be affixed to the

documentation. Please bundle documents for each claim separately to enable us to

ensure receipt of all requested documents.

3. Providers/suppliers are responsible for obtaining supporting documentation from

third parties (hospitals, nursing homes, suppliers, etc.).

4. Refer to the ‘Supporting Documentation’ attachment for a list of required

supporting documentation to be submitted.

5. The RAC is required to reimburse providers for the submission of medical records for the

following claim types: Acute Care Inpatient Prospective Payment System Hospital

Claims, Long Term Care Hospital Claims, non-PPS institution, and practitioners.

6. If you meet the Medicare definition of one of these provider types, you will be reimbursed

for the cost of providing copies of the additional documentation. Payment will be issued

to you within 45 days of receiving the additional documentation.

7. For PPS Providers, payment will be in the amount of $0.12 per page, plus the cost of First

Class postage, if mailed via USPS. For non-PPS Providers and practitioners, payment

will be in the amount of $0.15 per page, plus the cost of First Class postage, if mailed via

USPS. The amount per page, for the respective providers, will not exceed this quantity,

and the maximum payment per medical record, submitted via mail, fax, CD/DVD shall

not exceed $25.00. For medical records submitted electronically (via esMD), the “per

page” amount will be the same as those previously noted. However, the maximum

payment per medical record shall not exceed $27.00, including a $2.00 transaction fee.

8. Please do not include Powers of Attorney, Living Wills, Correspondence, or

Prior Episodes of Care.

9. Requirements for submitting imaged documentation on CD or DVD can be found at

(insert RAC web address) or by calling the RAC’s Call Center at XXX-XXX-XXXX.

Submission Methods

Providers/suppliers may submit this documentation in any of the following ways:

Via postal mail or Encrypted CD/DVD:

1. Include a copy of the ADR letter with your documents.

2. Mail to the following:

Regular Mail:

Company Name

Medical Review

Mail Code OR

Post Office Box

City, State Zip

Overnight Mail:

Company Name

Medical Review

Mail Code

Address

City, State Zip

Via fax to:

1. XXX-XXX-XXXX

2. Include a copy of the ADR letter with your documents.

Via Electronic Submission of Medical Documentation (esMD):

1. Include a copy of the ADR letter with your documents.

2. Submit your documentation to your CONNECT-compatible gateway or HIH.

3. More information on esMD can be found at www.cms.gov/esMD

Questions

If you have any questions please contact:

Recovery Auditor Audit Contractor Customer Service General Inquiry

XXX-XXX-XXXX

Address

City, State Zip

Sincerely, RAC Region X

Attachments / Supplementary Information

1. Claims Selected for Review Spreadsheet

Exhibit 46.4 – CERT Unified Post-payment ADR Sample Letter

(Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19)

Provider Name

Address 1

Address 2

City ST 00000

Date:

Reference ID: CID#

NPI/ Provider #:

Phone:

Fax:

Request Type & Purpose: New Request, Post-Payment Claim Review

Subject: Additional Documentation Required

Dear Medicare Provider/Supplier,

The Centers for Medicare & Medicaid Services (CMS), through the Comprehensive Error Rate

Testing (CERT) program, carries out the task of requesting, receiving, and reviewing medical

records1. The CERT program reviews selected Medicare A, B and DME claims and produces

annual improper payment rates. For more information regarding the CERT program, please visit

www.cms.gov/CERT.

Reason for Selection

The CMS’ CERT program has randomly selected one or more of your Medicare claims for

review.

Action: Medical Records Required

Federal law requires that providers/suppliers submit medical record documentation to support

claims for Medicare services upon request. Providers/suppliers are required to send supporting

medical records to the CERT program. Providing medical records of Medicare patients to the

CERT program does not violate the Health Insurance Portability and Accountability Act

(HIPAA). Patient authorization is not required to respond to this request. Providers/suppliers are

responsible for obtaining and providing the documentation as identified on the attached Bar

Coded Cover Sheet. The CMS is not authorized to reimburse providers/suppliers for the cost of

medical record duplication or mailing. If you use a photocopy service, please ensure that the

service does not invoice the CERT program.

1Social Security Act Sections 1833 [42 USC §1395l(e)] and 1815 [42 USC §1395g(a)]; 42 CFR 405.980-986

When: mm/dd/yyyy

Please provide the requested documentation by mm/dd/yyyy. A response is still required by

mm/dd/yyyy even if you are unable to locate the requested information.

Consequences

If the provider/supplier fails to send the requested documentation or contact CMS by

mm/dd/yyyy, the provider’s/supplier’s Medicare contractor will initiate claims adjustments or

overpayment recoupment actions for these undocumented services.

Instructions

Specific information and instructions pertaining to the sampled claim and returning requested

documents are shown on the following pages of this letter.

Please include the bar coded cover sheet with your submission.

Submission Methods

You may submit this documentation in any of the following ways:

• Via postal mail to:

CERT Documentation Center

1510 East Parham Road

Henrico, VA 23228

• Via Fax to: 804-261-8100 or 443-663-2698

1. Use the barcoded cover sheet as the only coversheet.

2. Do not add your own cover sheet—this slows down the receipt and identification

process

3. Send a separate fax transmission for each individual claim.

• Via Electronic Submission of Medical Documentation (esMD):

1. Include a CID# or Claim number and the barcoded cover sheet in your file

transmission.

2. Information on esMD can be found at www.cms.gov/esMD.

• Via CD:

1. The images should be encrypted per HIPAA security rules.

2. If encrypted, the password and CID# must be provided via

email to CERTMail@admedcorp.com or via fax to 804-264-

9764.

3. Must contain only images in TIFF or PDF format

• Via Email Attachment:

1. The email attachment(s) should be encrypted per HIPAA security rules.

2. If encrypted, the password and CID# must be provided via phone to 888-779-

7477 or via fax to 804-264-9764.

3. Must contain only attachments in TIFF or PDF format.

Questions

If you have any questions, please contact:

CERT Documentation Center

1510 East Parham Road

Henrico, VA 23228

Office: 443-663-2699 or Toll Free: 888-779-7477

Fax: 804-261-8100

Sincerely,

Contact Name

Director, Payment Accuracy & Reporting Group

Office of Financial Management

Centers for Medicare & Medicaid Services

Attachments / Supplementary Information

1. Claim Information

2. Bar Coded Cover Sheet

Exhibit 46.5 – SMRC Unified Postpayment ADR Sample Letter

(Rev. 884, Issued: 05-31-19, Effective Date: 08-30-19, Implementation Date: 08-30-19)

Letter Date:

Provider/Supplier Name

Provider/Supplier Address City,

State Zip

Project ID Number:

NPI/PROVIDER #:

PTAN:

Request Type & Purpose: Notification of Post-Payment Claim Review

Subject: Additional Documentation Required

Dear Medicare Provider/Supplier,

The Centers for Medicare & Medicaid Services (CMS) continually strives to reduce improper

payment of Medicare claims.10 As part of our effort to accomplish this goal, CMS has retained

“Contractor Name” as the Supplemental Medical Review Contractor (SMRC) to conduct a

medical record review of selected Part A and Part B claims. Additional information regarding

this contract can be found at: ‘website URL’.

Reason for Selection

Reason for Project for XXXX code(s):

• Service on Review - Short Description

This constitutes new and material evidence that establishes good cause for reopening the claim.

Providing additional documentation for each claim is authorized by CMS and is being

requested.

Action: Medical Records Required

Federal law

10 requires that providers/suppliers submit medical record documentation to support

claims for Medicare services upon request. Providing medical records of Medicare patients to

the SMRC does not violate the Health Insurance Portability and Accountability Act (HIPAA).

Patient authorization is not required to respond to this request.

When: mm/dd/yyyy

Please provide the requested documentation by mm/dd/yyyy. A response is still required by

mm/dd/yyyy even if you are unable to locate the requested information. Please note, you may

request an extension to submit the requested documentation, if your request is made by

mm/dd/yyyy.

10 Social Security Act Sections [42 USC 1320c-5(a) (3)], 1833 [42 USC 13951 (e)], and 42 CFR 405.980(b)

When the review is completed, you will receive a review results letter after a determination has

been made. The results letter will stipulate if any underpayment(s) or overpayment(s) were

identified.

Consequences

If you or your facility fail to send the requested documentation or request an extension by

mm/dd/yyyy, the “Contractor Name” will initiate claims adjustments or overpayment

recoupment actions with your Medicare Administrative Contractor for these undocumented

services.

Instructions

• This agency does not reimburse providers/suppliers for the cost associated with copying

of medical records from any setting. When records are requested, the expense of

supplying medical records is a part of the administrative costs of doing business with

Medicare. Therefore, invoices from record retention centers and copying agencies are not

eligible for reimbursement.

• Refer to the ADR Claim List for selected claims.

• A copy of this request letter should be affixed to the documentation submitted.

• All documentation should be submitted within 45 days of the date of this notice.

• Please refer to the Submission Methods section below for additional information on

document preparation and available submission methods.

• Refer to the enclosed SMRC Response Cover Sheet Form(s) for documentation

requirements.

• Note:

- Medicare requires that medical record entries for services provided/ordered be

authenticated by the author. The method used shall be a legible handwritten or

electronic signature.

- Stamp signatures are not acceptable. Beneficiary identification, date of service, and

provider of the service(s) should be clearly identified on the submitted documentation.

Documentation submitted in response to this request shall comply with these

requirements.

- This may require providers/suppliers to contact the hospital or other facility where

services were provided to obtain signed progress notes, plan of care, discharge

summary, etc.

- If signature requirements are not met, the reviewer will conduct the medical review

without considering the documentation with the missing or illegible signature. This

could lead the reviewer to determine that medical necessity for the service(s) billed has

not been substantiated.

- “Contractor name” recommends that providers review their documentation prior to

submission and ensure that all medical record entries and orders are signed

appropriately. For documentation with a missing, illegible or electronic signature, a

signature log or signature attestation may be submitted additionally as part of the ADR

response. For detailed guidance regarding Medicare signature requirements, refer to the

Medicare Program Integrity Manual, Publication 100-08, Chapter 3 and Section

3.3.2.4.

Submission Methods

Providers/suppliers may submit the documentation in any of the following ways:

• Include a copy of the Post Pay request letter with your documents.

• Complete the SMRC Response Cover Sheet Form (enclosed) for each

claim number requested and place on top of each set of documents to be

submitted.

• When submitting Post Pay ADR responses with multiple claims, make a

copy of the enclosed SMRC Response Cover Sheet Forms and send each

set of documents separately for each claim number.

• Via fax to: XXX-XXX-XXXX

• Via Electronic Submission of Medical Documentation (esMD):

− Convert all documents, including your cover sheets, to PDF.

− Submit your documentation to your CONNECT-compatible gateway or

HIH.

− More information on esMD can be found at www.cms.gov/esMD

• Via postal mail or Encrypted CD/DVD

− Image(s)s must be submitted in PDF or multi-page TIF format.

− If the CD/DVD is password protected, send an email to “Email Address”.

Include the Project Number from this letter, the package tracking number

and password.

Contractor Name and Mailing Address:

Questions

Thank you for your participation with this review. If you have any questions, please

contact:

Office: XXX-XXX-XXXX

Sincerely,

Supplemental Medical Review Contractor Program Manager

Attachments / Supplementary Information

1. SMRC Point of Contact Information

2. SMRC ADR Claim List

3. SMRC Response Cover Sheet Form(s)

Exhibit 47 – Program Integrity Unit Contacts within the State

Medicaid Agency

(Rev. 13000; Issued: 12-12-24; Effective: 12-10-24; Implementation: 12-10-24)

State POC Phon

e

POC E-mail Address

Alabama Beverly

Churchwell

(334)

242-

5318

Beverly.Churchwell@medicaid.alabama.go

v

Alaska Doug Jones

(907)

269-

0361

doug.jones@alaska.gov

American

Samoa

Matilda

Kruse

(684)

699-

4777

matilda.kruse@medicaid.as.gov

Arizona Vanessa

Templeman

(602)

877-

9066

Vanessa.Templeman@azahcccs.gov

Arkansas Heather

Callaway

(501)

687-

8349

Heather.callaway@arkansas.gov

California Bruce Lim

(916)

440-

7552

bruce.lim@dhcs.ca.gov

Colorado Bart

Armstrong

(303)

866-

4940

Bart.Armstrong@hcpf.state.co.us

Connecticut John

Jakubowski

(860)

424-

5855

John.Jakubowski@ct.gov

Delaware

Joe Riley

(acting)

(302)

255-

9647

Joe.Riley@delaware.gov

District of

Columbia

Kevin

O’Donnell

(202)

299-

5619

Kevin.Odonnell2@dc.gov

Florida Kelly

Bennett

(850)

412-

4600

Kelly.Bennet@ahca.myflorida.com

Georgia Johnny

Brooks

(404)

463-

7144

johnny.brooks@dch.ga.gov

Guam Jeffrey San

Nicolas

(671)

735-

7475

Jeffrey.Sannicolas@dphss.guam.gov

State POC Phon

e

POC E-mail Address

Hawaii Shelley

Siegman

(808)

692-

7962

SSiegman@dhs.hawaii.gov

Idaho Lori Stiles

(208)

334-

0653

stilesl@dhw.idaho.gov

Illinois Brian Dunn

(312)

833-

5835

Brian.J.Dunn@illinois.gov

Indiana Ben Ford

(317)

234-

7711

Benjamin.Ford@fssa.in.gov

Iowa Kimberly

Pierson

(515)

321-

8409

kpierso@dhs.state.ia.us

Kansas

Kansas

Department

of Health

and

Environmen

t

(785)

296-

1500 HCFProgramIntegrity@ks.gov

Kentucky Jennifer

Dudinskie

(502)

564-

5472

Jennifer.Dudinskie@ky.gov

Louisiana Angie Bihm

(225)

342-

9287

Angela.Bihm@LA.gov

Maine Valerie

Hooper

(207)

287-

4660

Valerie.Hooper@Maine.gov

Maryland Mary

Blackwell

(410)

767-

4332

Mary.Blackwell@Maryland.gov

Massachusett

s

Joan

Senatore

(617)

847-

3122

Joan.Senatore@state.ma.us

Michigan Michelle

Popowich

(517)

284-

6966

Popowichm@michigan.gov

Minnesota

Amanda

Novak

Kathryn

King-Scribbins

(651)

431-

6378

(651)

431-

6956

Amanda.novak@state.mn.us

kathryn.king-scribbins@state.mn.us

State POC Phon

e

POC E-mail Address

Mississippi Richard

Cameron

(601)

576-

4134

Richard.Cameron@medicaid.ms.gov

Missouri VACANT

Montana Heather

Smith

(406)

444-

4120

HeatherSmith@mt.gov

Nebraska Anne

Harvey

(402)

471-

1718

anne.harvey@nebraska.gov

Nevada Cynthia

Leech

(775)

684-

7964

Cleech@dhcfp.nv.gov

New

Hampshire

Karen

Carleton,

RN

Francesca

Hennessy

(603)

271-

8029

(603)

271-

5134

Karen.Carleton@dhhs.nh.gov

Francesca.Hennessy@dhhs.nh.gov

New Jersey

Joshua

Lichtblau

Don

Catinello

Nina

Galletto

(609)

292-

4368

(609)

789-

5014

(609)

789-

5031

Joshua.Lichtblau@osc.nj.gov

Don.Catinello@osc.nj.gov

Nina.Galletto@osc.nj.gov

New Mexico

Lisa V.

Medina-Lujan

(505)

827-

7310

Lisa.Medina-Lujan@hsd.nm.us

New York

Frank T.

Walsh, JR

(514)

473-

8782

Frank.Walsh@omig.ny.gov

North

Carolina

John E.

Thompson

(919)

527-

7701

John.E.Thompson@dhhs.nc.gov

North Dakota

Denise

Martino

(701)

328-

4024

Dmmartino@nd.gov

Northern

Mariana

Islands

Annie Rose

Z. Reyes

(670)

664-

4883

annierosezandueta@cnmimedicaid.com

State POC Phon

e

POC E-mail Address

Ohio Jeffrey

Corzine

(614)

387-

8369

Jeffrey.corzine@medicaid.ohio.gov

Oklahoma Julie Dowell

(405)

522-

7421

Julie.Dowell@okhca.org

Oregon

Fritz Jenkins

Tamara

McNatt

(503)

358-

5246

Fritz.Jenkins@odhsoha.oregon.gov

Tamara.McNatt@dhsoha.state.or.us

Pennsylvania

Karen

Fickes

(717)

705-

6858

kfickes@pa.gov

Puerto Rico

Maria D.

Garcia-

Ducos

(787)

765-

2929

Ext.

6756

maria.garcia.ducos@salud.pr.gov

Rhode Island

Christopher

Smith

(401)

463-

0163

Christopher.smith@ohhs.ri.gov

South

Carolina

Michael

Targia

(803)

898-

2608

Michael.Targia@scdhhs.gov

South Dakota Stacy Bruels

(605)

773-

3745

Stacy.Bruels@state.sd.gov

Tennessee Floyd Price

(615)

507-

6686

Floyd.N.Price@tn.gov

Texas Steve

Johnson

(512)

415-

7980

Steve.Johnson@hhs.texas.gov

Utah Gene

Cottrell

(801)

599-

4372

GCottrell@utah.gov

Vermont

Nadeth

Fitzgerald

(802)

760-

9432

Nadeth.Fitzgerald@vermont.gov

State POC Phon

e

POC E-mail Address

Virgin Islands Kevin

Dennin

(340)

774-

0930

Ext.

4478

Kevin.Dennin@dhs.vi.gov

Virginia Tracy

Sargent

(804)

371-

2648

Tracy.Westerman@dmas.virginia.gov

Washington Michael

Brown

(360)

725-

0913

Michael.brown@hcs.wa.gov

West Virginia Andrew

Pack

(304)

352-

4253

Andrew.C.Pack@wv.gov

Wisconsin

Anthony

Baize

(608)

266-

2521

Anthony.Baize@dhs.winsconsin.gov

Wyoming

Andrew

Chapin

Susan Malm

Portia

Peterson

(307)

777-

2504

(307)

777-

5609

(307)

777-

8985

Andrew.Chapin@wyo.gov

Susan.Malm@wyo.gov

Portia.Pterson1@wyo.gov

Step 3- Did the provider render a medically necessary

service

Severity of Signs and Symptoms, and

Step 2- Did the Patient Need Hospital Care?

Exhibit 48 - Guideline for Hospital Patient Status Reviews

(Rev. 13409; Issued: 09-12-25; Effective: 10-13-25; Implementation: 10-13-25)

Note- If any of the following unforeseen

circumstances

resulted in a shorter stay, the stay is payable

under Part A:

• Death,

• Transfer,

• Departures Against Medical

Advice (AMA),

• Clinical Improvement,

• Election of Hospice

No

Claim is NOT Payable

under Part A

Claim is NOT

Payable under

Part A

* Reviewers shall consider complex medical factors that support a reasonable expectation of the needed

duration of the stay relative to the 2 -midnight benchmark. Both the decision to keep the beneficiary at the

hospital and the expectation of needed duration of the stay are based on such complex medical factors as

beneficiary medical history and comorbidities, the severity of signs and symptoms, current medical needs,

and the risk (probability) of an adverse event occurring during the time period for which ho spitalization is

considered.

Legal Disclaimer: This educational product was prepared as a service to the public and is not intended to

grant rights or impose obligations. This educational product may contain references or links to statutes,

regulations, or other policy materials. The information provided is only intended to be a general summary. It

is not intended to take the place of either the written law or regulations. We encourage readers to review the

specific statutes, regulations, and other interpretive materials for a full and accurate statement of their

contents.

Exhibit 49 – Exhibit 49 – OMHA e-Appeal Portal

(Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26)

The OMHA e-Appeal Portal is a secure, web-based system that allows parties to

electronically manage Medicare appeals before OMHA, including submitting case

information and documents online instead of relying on paper and mail. The following

exhibits are designed to help users effectively utilize this system: one provides step-by-

step instructions for creating and accessing a portal account, and the other explains

how to upload appeal documents within the portal so that information is properly

associated with the correct case.

Exhibit 49.1 – OMHA e-Appeal Portal - How to Access the Portal

(Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26)

The OMHA e-Appeal Portal is available at <hhs-ecape-portal.entellitrak.com>.

Portal Account Creation:

To create a new portal account, navigate to the website at <hhs-ecape-portal.entellitrak.com>. Then select the green button labeled “Sign in with ID.me.”

You will be redirected to ID.me and prompted to sign in or create an ID.me account.

The portal utilizes ID.me to provide identity verification for new accounts and multi-factor authentication for secure sign-in to existing accounts. Creating an ID.me

account requires a picture ID (such as a driver's license or passport) and an email

address or phone number for verification. It usually takes about 15-20 minutes. In some

situations, a live video call may be required to verify a new user’s identity.

Once you finish signing in to or creating an account with ID.me, you will be redirected

back to the portal’s user registration page and prompted to enter some profile

information. Once you’ve entered the required information, click “Register” and you

will be directed to your portal account’s home page.

Portal Account Sign-in:

To sign-in to an existing portal account, navigate to the website at <hhs-ecape-portal.entellitrak.com>. Then select the green button labeled “Sign in with ID.me.”

You will be redirected to ID.me and prompted to sign in with multi-factor

authentication to your ID.me account. Once you have signed into ID.me, you will be

transferred to your portal account’s home page.

Exhibit 49.2 – How to Upload Documents via the OMHA e-Appeal

Portal

(Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26)

To upload documents to an existing Level 3 appeal, sign-in to the portal. From the

main page, select the “Upload Additional Documents to an Appeal tab” on the left side

of the page.

Enter the OMHA appeal number and then select the file(s) you wish to upload to the

appeal by clicking the “Add Another File” button.

Once the OMHA appeal number is entered and the desired files are added, click

“Submit.”

A confirmation pop-up question will appear, asking “Are you sure you would like to

submit the Attachment?” Click “OK.”

After you select “OK,” a screen will appear to confirm the files were uploaded. The

appeal number and the file name(s) uploaded will be listed. You will also receive an email confirmation.

Note: Use caution when entering the appeal number to avoid adding files to the wrong

appeal. Avoid using any spaces before or after the appeal number. The Administrative

Law Judge and team assigned to the appeal will receive an alert that a document was

uploaded to the appeal. You may upload multiple documents, but each file is restricted

to 50MB. If the file is larger than 50MB, it will need to be broken down into smaller

files and then uploaded. The following file types can be uploaded: PDF, RTF, Word,

Excel, PowerPoint, BMP, JPEG, PICT, TIFF, CSV, and XML.

Exhibit 50 – UPIC and I-MEDIC Fax Cover Sheet

(Rev. 13595; Issued: 01-26-26; Effective: 02-26-26; Implementation: 02-26-26)