Claims Where There is Evidence That Items or Services Were Not Furnished or

280.3 - Claims Where There is Evidence That Items or Services Were Not Furnished or Were Not Furnished as Billed (Rev. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) Where there is a substantial basis for determining that an item or service either was not furnished or was not furnished as billed, the MAC may deny or down-code payment, as appropriate. The reviewer must ensure that the case file clearly documents the evidence that formed the basis for the determination. Appeal rights after such a determination remain the same as they would for any other unfavorable decision. If the MAC has reason to believe or evidence to support that items or services were not furnished or were not furnished as billed, it shall send a copy of the decision to its UPIC.