Medical Review Guidance

3.3.2 - Medical Review Guidance (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) This section applies to MACs, CERT, Recovery Auditors, and UPICs, as indicated. This section describes the requirements that MACs, CERT, Recovery Auditors, and UPICs shall follow when reviewing submitted documentation. Additional requirements for UPICs are located in PIM chapter 4. When UPIC staff is performing benefit integrity reviews, their focus is different than that of MACs, CERT, and Recovery Auditors. For example, UPIC staff looks for some of the following situations when reviewing documentation: • Possible falsification or other evidence of alterations including, but not limited to: obliterated sections; missing pages, inserted pages, white out; and excessive late entries; • Evidence that the service billed for was actually provided; or, • Patterns and trends that may indicate potential fraud.