Administrative Actions

4.11.2 - Administrative Actions (Rev.: 11696; Issued: 11-09-22; Effective: 12-12-22; Implementation: 12-12-22) The UPICs, SMRCs and MACs shall ensure that the program rules and regulations are being appropriately followed. If violations are noted (either through internal reviews or through a complaint process), the contractor shall take the appropriate steps to inform and educate the provider of the non-compliance and encourage future compliance. For MACs, if, after a period of time, there is no significant change by the provider (the non- compliance continues), then a final warning notice of plans to propose a corrective action (such as a CMP) shall be issued. This notice shall be sent by certified mail (return receipt required), other courier service with a signature required, or provider/ Electronic Submission of Medical Documentation (esMD) portal (with evidence of receipt). The notice shall indicate that previous notifications sent to the provider failed to correct the problem, and that this is a final warning. Additionally, it shall indicate that any further continuation of the non- compliance will result in the matter being forwarded to CMS or the OIG for administrative enforcement. While not specifically assessing a monetary penalty amount, the notice shall indicate that this is one type of sanction that may be applied.