UPIC and I-MEDIC Responsibilities

4.5.1 - UPIC and I-MEDIC Responsibilities (Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26) This section applies to the UPICs and the MACs. When a complaint is received from the MAC screening staff, the UPIC shall further screen the complaint, resolve the complaint, or make referrals, as needed, to the appropriate entity. The MAC shall screen and forward the complaints within 45 business days from the date of receipt by the screening staff, or within 30 business days of receiving medical records and/or other documentation, whichever is later, to the UPIC. The UPIC shall send the acknowledgement letter within 15 calendar days of receipt of the complaint referral from the MAC screening staff, unless it can be resolved sooner. The letter shall be sent on UPIC letterhead and shall contain the telephone number of the UPIC analyst handling the case. If the MAC refers a DME provider/supplier that was previously referred to the UPIC, is under active investigation, is on an active Payment Suspension, has been referred to law enforcement and is under active law enforcement investigation, or is under an active zone restriction, the UPIC shall not send the following letters to the beneficiary/complainant. • Acknowledgement within 15 calendar days of receipt of the complaint referral from the MAC screening staff unless it can be resolved sooner; • Acknowledgement to the complainant, indicating that a referral is being made, if applicable, to the appropriate MAC unit for further action; • Complaint resolution within seven (7) calendar days of resolving the complaint investigation. The UPIC shall document the MAC referral/complaint in the active investigation file (CSE) in UCM as well as upload the referral/complaint in the Documents section of the active CSE. Should the UPIC need additional beneficiary interviews, the UPIC should consider interviewing beneficiaries that have filed a complaint. If the UPIC staff determines, after screening the complaint, that it is not a potential fraud, waste, and/or abuse issue, but involves other issues (e.g., MR, enrollment, claims processing), the complaint shall be referred back to the MAC area responsible for screening. The MAC screening staff shall track the complaints returned by the UPIC. However, the UPIC shall send an acknowledgement to the complainant, indicating that a referral is being made, if applicable, to the appropriate MAC unit for further action. The UPIC shall track complaints referred by the MAC screening area in the UPIC’s internal tracking system. The UPIC shall send the complainant a resolution letter within seven (7) calendar days of resolving the complaint investigation. This section applies to UPICs who receive identified potential user abuse of MBI Lookup Tools in MAC portals. When CPI identifies potential user abuse in the MBI Lookup tool, CPI will enter a case in the UCM, screen and vet as needed, and tag the case as an MBI Lookup violation. CPI will advise the applicable UPIC(s) of the details of the case and request an investigation into inappropriate claim submissions, if applicable. This section applies to the I-MEDIC. When a complaint is received by the I-MEDIC complaint screening staff, an acknowledgement letter shall be sent to the complainant within five (5) calendar days. The I-MEDIC complaint screening staff shall screen, resolve, or if warranted, escalate the complaint to the screening team at the I-MEDIC within 30 calendar days from the date of receipt. Once a complaint has been escalated to lead screening, the I-MEDIC shall further screen the lead, open an investigation, or make referrals, as needed, to the appropriate entity within 45 days. The I-MEDIC shall track all complaints received by its complaint screening staff in an internal tracking system. All complaints that have escalated to a lead status shall be tracked in the UCM. The I-MEDIC complaint screening staff shall send the complainant a resolution letter within five (5) calendar days of resolving the complaint investigation.