Revision to Medicare Administrative Contractor (MAC) Complaint Screening Process - Checking the Recovery Audit Contractor (RAC) Data Warehouse (RACDW) Prior to Claim Adjustment
The purpose of this Change Request (CR) is to require the MAC to check the RACDW for suppressions and/or exclusions, prior to claim adjustment as the result of a second-level screening. If a suppression and/or exclusion is present, the MAC shall not adjust the claim, and the complaint or inquiry shall be closed. However, if the MAC determines that the complaint or inquiry indicates potential fraud, and a suppression/exclusion is not present, the MAC shall make a referral to the Unified Program Integrity Contractor (UPIC), using the referral guidelines established in section 4.6.2.4 – (Referrals to the UPIC) in chapter 4 of Publication (Pub.) 100-08.
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: September 17, 2021
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