Contractor Coordination and Suppression and Exclusion

4.2.2.8.1.4 – Contractor Coordination and Suppression and Exclusion Upload Requirements Related to the RAC Data Warehouse (Rev. 13879; Issued: 07-23-26; Effective: 08-24-26; Implementation: 08-24-26) This section applies to all medical review contractors (UPIC, RAC, MAC, SMRC) uploading suppression and exclusions into the RACDW unless otherwise noted. The CMS utilizes the RAC Data Warehouse (RACDW) to track review contractor activity. The RACDW allows contractors that perform medical reviews to prevent duplicative claim reviews by using the Suppressions and Exclusions process. For assistance with file errors, contact the system administrators at helpdesk.RACDW@koniag-gs.com. Current suppression/exclusion file layouts are available by download from the RACDW itself. Suppressions: Suppressions are used by Non-RAC entities to identify a set of claims as temporarily off-limits for selection by other review entities. The set of claims are identified by using the current suppression file layout, which utilizes parameters to narrow the universe of suppressed claims. Suppression Requirements: Suppressions shall be entered using the most current suppression file layout found in the RACDW. All required fields shall be submitted upon initial upload. The Suppression file layout does not allow the suppression of claims with a paid date older than 3 years. Individual NPIs or legacy numbers shall be entered for each suppression. If a provider has multiple NPIs or legacy numbers, the RACDW will only suppress uploaded NPIs or legacy numbers. Any error codes generated from the system shall be corrected by the uploading entity before successful upload can be completed. Unless other parameters have been included on the initial upload, all suppressions will automatically expire within 12 months of the date they were entered into the RACDW. If a suppression is required for longer than 12 months, the contractor shall re-new the suppression prior to the expiration date. The individual user that uploaded a suppression file shall be responsible for releasing any suppressions in that file that are no longer valid within 2 business days. Data entered in the situational fields in the suppression file layout shall require an additional narrative in the comments field for final approval. The contractor shall be responsible for correcting and re-uploading any disapproved suppressions within 2 business days of the disapproval. Exclusions: Exclusions are claims that have been previously reviewed by a medical review entity (or that are part of an extrapolated settlement universe). They are identified by specific claim number uploaded into the RACDW utilizing the current exclusion file layout and are permanently flagged as unavailable for additional review by a review contractor. Exclusion Requirements: Exclusions shall be entered using the most current version of the exclusion file layout found in the RACDW. All required fields shall be submitted upon initial upload. Any error codes generated from the system shall be corrected before successful upload can be completed. UPIC-Specific Requirements for Suppressions and Exclusions: The UPIC shall enter suppressions in the RACDW as soon as the investigation begins, no later than 2 business days after the investigation is opened. UPICs can renew any active suppressions that are within 30 days of their expiration date. To do so, the UPIC shall provide a new date, add ‘Renewal’ in the justification space, and resubmit the entry for approval in the RACDW. The UPIC shall release suppressions within 2 business days of the underlying investigations/cases being closed. Statistically Valid Random Sampling (SVRS): In the event that the UPIC is unable to determine at the time of review whether any overpayments that are identified will be extrapolated to the parent claim universe, the UPIC shall enter a suppression utilizing the current file layout. If the UPIC does ultimately assess an extrapolated overpayment, the UPIC shall release the suppression and exclude the entire universe. If the overpayment is computed based only on the sampled claims (i.e., the overpayment is not projected to the entire universe), the UPIC shall release the suppression and exclude only the sample claims that were actually reviewed. If a provider is under review by another contractor (RAC, MAC, SMRC), the UPIC shall contact that contractor to determine which entity should continue to review that provider and how to proceed with the current medical review, such as closing it out or completing the medical review and then referring it to the UPIC.