Documents on Which to Base a Determination

3.3.2.1 - Documents on Which to Base a Determination (Rev. 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) This section applies to MACs, CERT, RACs, SMRC and UPICs, as indicated. The MACs, CERT, RACs, SMRC, and UPICs shall review any information necessary to make a prepayment and/or post-payment claim determination, unless otherwise directed in this manual. This includes reviewing any documentation submitted with the claim and any other documentation subsequently requested from the provider or other entity when necessary. In certain circumstances it may be appropriate for medical reviewers to consider relevant and accessible billing history or other information obtained from the Common Working File (in limited circumstances), outcome assessment and information set (OASIS), or the minimum data set (MDS), among others. For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary’s medical documentation and confirm that Medicare coverage criteria have been met.