Updates to CMS Program Integrity Manual
October 20, 2015 09:26 AM
CMS posted Change Request (CR) 9226 effective November 17, 2015. This CR is a clarification in operational procedures for CMS contractors and updates Chapter 3 of the Program Integrity Manual. In some instances, the contractors (MACs, CERT, Recovery Auditors, and Zone Program Integrity Contractors (ZPICs)) may not be able to make a determination on a claim they have chosen for review based upon the information on the claim, its attachments, or the billing history found in claims processing system (if applicable) or the Common Working File (CWF). In those instances, the reviewer shall solicit documentation from the provider or supplier by issuing an additional documentation request (ADR).
Because there are no statutory provisions requiring that postpayment review of the documentation be completed within a certain timeframe, MACs and CERT shall grant at least one extension to providers who need more time to comply with the request. ZPICs shall have the discretion to grant extensions to providers/ suppliers who need more time to comply with the request. The number of submission extensions and the number of days for each extension is solely within the discretion of the MACs, CERT and ZPICs. RACs shall follow the time requirements outlined in their SOW.