Unified Program Integrity Contractor (UPIC) Coordination with Other Contractors Related to the Recovery Audit Contractor (RAC) Data Warehouse (RACDW) - Exclusion Clarification
The purpose of this Change Request (CR) is to revise the following statement in section 4.33 of Chapter 4 in Publication (Pub.) 100-08: "Once a suppression is lifted or expires,
UPICs are also responsible for entering any necessary exclusions. Any claims for which the UPIC has requested medical records shall be excluded to prevent re-review by a RAC,
unless the UPIC’s review resulted in a full denial. In this case, exclusion is unnecessary because the provider/supplier will either appeal and the redetermination entity will enter
the exclusion, or the provider/supplier will allow the decision to stand. The exclusion will be unnecessary because the RACs are unlikely to pursue zero-dollar claims)," to state
only that, "Once a suppression is lifted or expires, UPICs are also responsible for entering any necessary exclusions. Any claims for which the UPIC has requested medical records
shall be excluded to prevent re-review by a RAC." There is no exception in the case of a full denial.
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: December 10, 2020
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