Immediate Advisements to the OIG/OI

4.9.1 – Immediate Advisements to the OIG/OI (Rev. 13879; Issued: 07-23-26; Effective: 08-24-26; Implementation: 08-24-26) The UPIC shall notify the OIG/OI of an immediate advisement as quickly as possible, but not more than four (4) business days after identifying a lead or investigation that meets the following criteria. UPICs are not required to submit an IA for leads or investigations initiated from an OIG Hotline referral that has already been reviewed by OIG/OI, unless new allegations, new information, or program vulnerabilities are identified that warrant re-notification to OIG/OI. The UPIC shall maintain internal documentation on these advisements when it receives allegations with one or more of the following characteristics: • Indications of UPIC or MAC employee fraud • Allegations of kickbacks or bribes, discounts, rebates, and other reductions in price • Allegations of a crime committed by a federal or state employee in the execution of their duties • Indications of fraud by a third-party insurer that is primary to Medicare • Confirmation of forged documentation during the course of an investigation, include, but is not limited to: • identification of forged documents through medical review; and/or • attestation from provider confirming forged documentation. • Allegations and subsequent verification of services not rendered as a result of any of the following: • Medical review findings; • Interviews or attestations from a minimum of three (3) beneficiaries indicating that they did not receive services; and/or • Attestations from referring/ordering providers indicating they did not refer/order a service (e.g., confirmation of no relationship with the beneficiary prior to service, or confirmed impossible day billings). • Confirmed complaints from current or former employees that indicate the provider in question inappropriately billed Medicare for all or a majority of its services. Confirmation would be required though one of the following: • Minimum of three (3) beneficiary interviews confirming the inappropriate billing; • Provider attestation(s) confirming the inappropriate billing; or o medical review findings. • Confirmation of beneficiary recruitment into potentially fraudulent schemes and/or provider participation (e.g., telemarketing or solicitation schemes); • Substantiated identity theft of a provider’s Medicare number, a beneficiary’s Medicare number, or selling or sharing of beneficiary lists; • Confirmed indication of patient harm (e.g., through medical review findings or confirmation of issues identified during an onsite visit or interviews with providers or beneficiaries). • Indication of provider/supplier fraud related to national emergency, pandemic, etc. • Should an IA of this nature be identified, the UPIC shall notify their BFL to determine if the IA should be forwarded to a specific OIG/OI point-of- contact. IAs should be referred to the OIG/OI only when the above criteria are met, unless prior approval is given by the BFL, with the exception of OIG hotline referrals, unless new information is identified. Should local LE have specific parameters or thresholds in place that do not allow them to accept certain IAs, the UPIC shall notify its BFL, with a copy to the COR, and request exemption from the applicable IA criteria in that particular jurisdiction. When IA criteria are met, the UPICs shall perform an initial assessment to identify and document dollars currently pending payment to the provider. Should high dollar amounts be identified with either scenario, the UPIC shall notify CMS immediately, but not to exceed two (2) business days from date of identification. Once the criteria for an IA are met, the UPIC shall notify the OIG/OI via phone or email to determine if a formal IA referral should be sent to the OIG/OI. If the IA is related to a provider/supplier that spans multiple jurisdictions, the UPIC shall notify any impacted UPIC and/or I-MEDIC Program Directors of the potential IA, allegation, and IA criteria. The UPIC shall document this communication in UCM. The UPIC shall also send notification to its appropriate BFL, with a copy to the COR, of the potential IA. If the UPIC does not receive a response from the OIG/OI within two (2) business days (5 business days for the I- MEDIC), it shall notify its appropriate BFL, with a copy to the COR, and await further instructions. If the OIG/OI confirms that a formal IA should be sent, the UPIC shall provide all available documentation, including billed/paid amounts for the YTD and the previous year, to the OIG/OI within four (4) business days of receiving the response from OIG/OI. Upon submission of the IA to the OIG/OI, the UPIC shall request written and/or email confirmation from the OIG/OI acknowledging receipt of the IA. Simultaneously, the UPIC shall notify the CMS identified Strike Force points of contacts, if the notification includes providers/suppliers located within a Strike Force jurisdiction. Additionally, the UPIC shall notify and send a copy of the IA to its COR/BFL and the case coordination team, at CPIMCCNotifications@cms.hhs.gov, the same day the advisement is made to OIG/OI. In this notification to CMS, the UPIC shall advise if it has any other potential administrative actions it may want to pursue related to the provider(s)/supplier(s). The provider(s)/supplier(s) identified in an accepted IA shall be added to the UPIC’s next scheduled case coordination meeting. If the OIG/OI determines that a formal IA is not needed, the UPIC shall advise its appropriate BFL, with a copy to the COR, and immediately continue its investigation. In instances where an IA is related to a Plan employee whistleblower, the I-MEDIC does not have to notify the case coordination team of the IA nor does the IA have to be discussed at a case coordination meeting. Rather, the I-MEDIC shall close the complaint upon acceptance and/or declination of the IA due to these complaint types being outside of the I-MEDIC’s SOW. If the IA is related to a provider/supplier that spans multiple jurisdictions, the UPIC shall send a notification to the other UPIC and/or I-MEDIC Program Directors on the same date the formal IA is sent to OIG/OI. The UPIC shall copy its COR/BFL on such communication. Upon receipt of the notification from the primary UPIC, the other UPICs and/or I-MEDIC shall provide confirmation to the primary UPIC and its COR/BFL that the notification has been received, and it is ceasing activity as instructed below. Upon receipt of acceptance or declination of the IA from the OIG/OI, the primary UPIC shall notify the other UPIC and/or I-MEDIC Program Directors of the outcome. Upon identification and submission of an IA to the OIG/OI, unless otherwise directed, all impacted UPICs and/or I-MEDIC shall cease all investigative and administrative activities, with the exception of screening activities, data analysis, etc., until the OIG/OI responds with its acceptance or declination of the IA. If the UPIC does not receive an immediate response from the OIG/OI, the UPIC shall contact OIG/OI after two (2) business days from the date of the IA notification and document the communication in the UCM system. If the UPIC does not receive a response from the OIG/OI within five (5) business days from the date of the IA notification, the UPIC shall contact its appropriate BFL, with a copy to the COR, for further guidance. If the OIG/OI declines or accepts the IA, the UPIC shall document the decision in UCM and follow the processes described in Chapter 4, § 4.5, 4.6, and 4.7 of the PIM, unless otherwise directed by CMS. Additionally, until the necessary updates are made in the UCM, if the UPIC submits an IA based on the updated criteria, it shall select all six (6) IA options on the “External Stakeholders” page of the UCM, and notate the justification of the IA in the Record Summary section of the UCM. During the case coordination meeting, the UPIC may receive additional guidance from CMS related to subsequent actions related to the IA. If the UPIC has questions following the case coordination meeting, the UPIC shall coordinate with its appropriate BFL, with a copy to the COR. Medicare Program Integrity Manual Exhibits Transmittals for Exhibits Exhibit 16 - Model Payment Suspension Letters A. Payment Suspension Initial Notice of Suspension Based on Fraud [UPIC Information Header] Confidentiality Notice: This message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender and destroy all copies of the original message. To: [Provider Name] Attn: [Point of Contact] [Provider Street Address] [Provider City, State Zip code] From: [UPIC Name - UPIC Region][Street Address] [City, State, Zip Code] The remainder of this page is intentionally blank. Delivery Method: [INSERT] [Date] To: [Provider Name] Attn: [Point of Contact] [Provider Street Address] [Provider City, State Zip Code] Reference Number: [INSERT HERE] Provider Name: [INSERT HERE] Provider NPI: [INSERT HERE] Provider PTAN: [INSERT HERE] Subject: Notice of Suspension of Medicare Payments Dear [Point of Contact]: [Use the following template to construct a Notice of Suspension (NOS) for a credible allegation of fraud payment suspension. All NOS shall retain the formatting established in this template. The body of the NOS shall be formatted to “justified” text alignment.] The purpose of this letter is to notify you that the Centers for Medicare & Medicaid Services (CMS), after consulting with the Department of Health and Human Services Office of Inspector General, has decided to [SELECT FULL OR PARTIAL SUSPENSION LANGUAGE: fully suspend Medicare payments to , (), pursuant to 42 C.F.R. § 405.371(a)(2) and 42 C.F.R. § 405.372(a)(4). OR partially suspend Medicare payments to at a rate of [X]%, pursuant to 42 C.F.R. § 405.371(a)(2) and 42 C.F.R. § 405.372(a)(4).] [SELECT NO PRIOR NOTICE OR PRIOR NOTICE LANGUAGE: The suspension of Medicare payments took effect on [Month Day, Year]. Prior notice of this suspension was not provided because giving prior notice would place additional Medicare funds at risk and hinder CMS’ ability to recover any determined overpayment. See 42 C.F.R. §§ 405.372(a)(3). OR The suspension of Medicare payments will take effect on [Month Day, Year].] The decision to suspend Medicare payments is based on credible allegations of fraud. CMS regulations define credible allegations of fraud as allegations from any source including, but not limited to, fraud hotline complaints verified by further evidence, claims data mining, and patterns identified through audits, civil false claims cases, and law enforcement investigations. 42 C.F.R. § 405.370(a). Allegations are considered to be credible when they have indicia of reliability. Id. This suspension will last until resolution of the ongoing investigation, as defined under 42 C.F.R. § 405.370(a). Allegation(s) The suspension of Medicare payments to is based on, but not limited to, information that misrepresented services billed to the Medicare program. Specifically, the suspension of Medicare payments is based on the following allegation(s) as well as the example claims below, which we have included to provide evidence of the findings. Allegation # (Rename this “Allegation 1” if there is more than one allegation.): [Refer to Attachment A – Notice of Suspension Language Guide, Step 1 to identify and insert the approved language reflective of the primary allegation. Insert the appropriate approved language HERE.] 1 [See Attachment A, Step 2 to identify and insert the approved language reflective of the subparagraph detail associated with the primary allegation.] [Insert claim examples relevant to the subparagraph detail. Add rows if necessary. If one claim box is used for multiple subparagraph details of an allegation, the below statement should be inserted after the last subparagraph detail, before the claim box: “The below claim control numbers (CCNs) are examples of the allegations listed above.”] Claim Control Number (CCN) Date(s) of Service MM/DD/YYYY 2 [If necessary, add additional subparagraph detail associated with the primary allegation. Use Attachment A, Step 2 to identify the approved language reflective of the necessary subparagraph detail.] [If additional subparagraph detail is added above, insert claim examples relevant to the subparagraph detail. Add rows if necessary.] CCN Date(s) of Service MM/DD/YYYY Allegation 2: (If another primary allegation needs to be added, repeat all steps listed above. Continue repeating these steps to add allegations (e.g., Allegation 2, Allegation 3, etc.) as necessary. If a secondary allegation is identified, use Attachment A, Step 3 to insert the applicable approved language. If no additional allegations are needed after the primary allegation, delete this section and move on.) Investigation Process The investigation into this matter is ongoing, and the claims listed above represent only a sample of the problematic claims identified. The summary of allegations and the claims listed above provide notice of the reasons for the payment suspension. As the investigation continues, you may be asked to provide information. must be responsive to requests for documentation and information to prevent claim denials and other administrative actions. Right to Rebut Pursuant to 42 C.F.R. § 405.372(b), you have the right to submit a written rebuttal statement, including evidence supporting your rebuttal statement. Evidence provided in your rebuttal should be specific to each allegation on which the suspension was based, including but not limited to the claim examples provided. Merely providing general assertions or denials typically will be insufficient to overcome the allegation(s). Your rebuttal statement should be received within 15 business days of receipt of this notice. Requests for additional time to submit a rebuttal statement will be considered on a case- by-case basis. If you choose to submit a rebuttal statement, your rebuttal statement should be sent to: [UPIC Region] Unified Program Integrity Contractor[Street Address] [City, State, Zip Code] Notice of Rebuttal Response The suspension of Medicare payments will continue while your rebuttal statement is being reviewed. See 42 C.F.R. § 405.375(a). You will be notified in writing of the response. The response notice will include the findings regarding each allegation or condition upon which the suspension is based and an explanation as to why the suspension of Medicare payments will continue or be terminated. See 42 C.F.R. § 405.375(b)(2). The response following your rebuttal is not an initial determination and is not appealable. See 42 C.F.R. § 405.375(c). Disposition of Suspended Funds The suspension of Medicare payments is based upon credible allegations of fraud, and, as such, a determination will be made regarding an overpayment. A final decision regarding any overpayment may be delayed until the resolution of the investigation. See 42 C.F.R. § 405.372(c)(2). An investigation is resolved when “legal action is terminated by settlement, judgment, or dismissal, or when the case is closed or dropped because of insufficient evidence to support the allegations of fraud.” 42 C.F.R. § 405.370. If an overpayment is determined, you will receive a separate written notice from the Medicare Administrative Contractor that processes the Medicare claims you submit, Click here to enter Name of MAC, advising you of the reasons for the overpayment determination. 42 C.F.R. § 405.921(b). When the payment suspension has been removed, any money withheld as a result of the payment suspension shall be applied first to reduce or eliminate any overpayment, including any interest assessed under 42 C.F.R. § 405.378, and then to reduce any other obligation to CMS or to the U.S. Department of Health and Human Services in accordance with 42 C.F.R. § 405.372(e). In the absence of a legal requirement that the balance be paid to another entity, the excess will be released to . Processing of Claims During the Suspension Claims will continue to be processed during the suspension period. You will be notified about bill/claim determinations, including appeal rights regarding any bills/claims that are denied. The payment suspension also applies to claims in process. [INSERT the following paragraph IF the provider is going to be placed on prepayment review as part of the payment suspension.] Also, CMS [SELECT ONE: is continuing OR has implemented] the process of reviewing your Medicare claims and supporting documentation prior to payment. The purpose of the prepayment process is to ensure that all payments made by the Medicare program are appropriate and consistent with Medicare rules, regulations and policy. Notification is hereby given that you are expected to comply with the prepayment process for claims for all dates and services. Statutory Obligation to Return Overpayments As a Medicare provider, you are responsible for monitoring compliance with Medicare requirements. Upon discovering that payments were received in error, you are statutorily required to return the overpayments within 60 days. See § 1128J(d)(2) of the Social Security Act and 42 C.F.R. § 401.305. If you have any questions regarding the status of the suspension, please direct your inquiry to . Any request to remove the suspension must be submitted through the written rebuttal process described above. Sincerely, [UPIC Company Name] – A CMS Unified Program Integrity Contractor cc: Centers for Medicare & Medicaid Services B. Payment Suspension Initial Notice Based on Reliable Information (No Prior Notice Given) Date Name of Addressee (if known) Name of Medicare Provider/Supplier Address City, State Zip Re: Notice of Suspension of Medicare Payments Provider/Supplier Medicare ID Number(s): Provider/Supplier NPI: PSP Number: Dear {Medicare Provider/Supplier’s Name}: The purpose of this letter is to notify you of our determination to suspend your Medicare payments {INSERT THE FOLLOWING IF THIS IS A NATIONAL PAYMENT SUSPENSION: in all jurisdictions} pursuant to 42 C.F.R. § 405.371(a)(1). The suspension of your Medicare payments took effect on {ENTER DATE}. This payment suspension may last for up to 180 days from the effective date and may be extended under certain circumstances. See 42 C.F.R. § 405.372(d). Prior notice of this suspension was not provided, because giving prior notice would place additional Medicare funds at risk and hinder the Centers for Medicare & Medicaid Services’ (CMS) ability to recover any determined overpayment. See 42 C.F.R. § 405.372(a)(3) and (4). The CMS through its Central Office made the decision to suspend your Medicare payments. See 42 C.F.R. § 405.372(a)(4)(iii). The suspension of your Medicare payments is based on reliable information that an overpayment exists or that the payments to be made may not be correct. Specifically, the suspension of your Medicare payments is based on, but not limited to, information from claims data analysis and medical review completed by {NAME OF UPIC or MAC}. More particularly, {Continue with further supportive information and specific claim examples (no less than five). Only use claim numbers, date of service, amount paid and basis for selected claim when referencing the claim examples. Do Not use beneficiary names or HIC#s in the notice.}. The following list of sample claims provide evidence of our findings and serve as a basis for the determination to suspend your Medicare payments: Claim Control NumberDate(s) of Service$$ Amount Paid Basis for Selected Claim This list is not exhaustive or complete in any sense, as the investigation into this matter is continuing. The information is provided by way of example in order to furnish you with adequate notice of the basis for this payment suspension. Pursuant to 42 C.F.R. § 405.372(b)(2), you have the right to submit a rebuttal statement in writing to us indicating why you believe the suspension should be removed. If you opt to do so, we request that you submit this rebuttal statement to us within 15 days and you may include with this statement any evidence supporting your reasons why the suspension should be removed. If you choose to submit a rebuttal statement, your rebuttal statement and any pertinent evidence should be sent to: {YOUR NAME}, Program Integrity Analyst {ADDRESS} If you submit a rebuttal statement, we will review that statement (and any supporting documentation) along with other materials associated with the case. Based on a careful review of the information you submit and all other relevant information known to us, we will determine whether the suspension should be removed or should remain in effect within 15 days of receipt of the complete rebuttal package, consistent with 42 C.F.R. § 405.375. However, the suspension of your Medicare funds will continue while your rebuttal package is being reviewed. See 42 C.F.R. § 405.375(a). Thereafter, we will notify you in writing of our determination to continue or remove the suspension and provide specific findings on the conditions upon which the suspension may be continued or removed, as well as an explanatory statement of the determination. See 42 C.F.R. § 405.375(b)(2). This determination is not an initial determination and is not appealable. See 42 C.F.R. § 405.375(c). If the suspension is continued, we will review additional evidence during the suspension period to determine whether claims are payable and/or whether an overpayment exists and, if so, the amount of the overpayment. See 42 C.F.R. § 405.372(c). We may need to contact you with specific requests for further information. You will be informed of developments and will be promptly notified of any overpayment determination. We will continue to process claims during the suspension period, and you will be notified about bill/claim determinations, including appeal rights regarding any bills/claims that are denied. The payment suspension also applies to claims in process. In the event that an overpayment is determined and it is determined that a recoupment of payments under 42 C.F.R. § 405.371(a)(3) should be put into effect, you will receive a separate written notice of the intention to recoup and the reasons. Please be advised that CMS may charge interest on the amount of the overpayment, consistent with 42 C.F.R. § 405.378. In the written notice alerting you to the overpayment, you will be given an opportunity for rebuttal in accordance with 42 C.F.R. § 405.374 from {MAC name}, CMS’ Medicare Administrative Contractor (MAC). When the payment suspension has been removed, any money withheld as a result of the payment suspension shall be applied first to reduce or eliminate any determined overpayment by CMS including any interest assessed under 42 C.F.R. § 405.378, and then to reduce any other obligation to CMS or to the U.S. Department of Health and Human Services in accordance with 42 C.F.R. § 405.372(e). In the absence of a legal requirement that the excess be paid to another entity, the excess will be released to you. {Insert the following paragraph if prepayment review is being initiated} Finally, {Name of UPIC or MAC}, a CMS {Unified Program Integrity Contractor (UPIC) or MAC}, has initiated a process to review your Medicare claims and supporting documentation prior to payment. The purpose of implementing this prepayment process is to ensure that all payments made by the Medicare program are appropriate and consistent with Medicare rules, regulations and policy. The prepayment process is often applied to safeguard Medicare from unnecessary expenditures and to ensure that Medicare payments are made for items and services which are “reasonable and necessary” for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. See 42 U.S.C. § 1395y(a)(1)(A). Notification is hereby given that you are expected to comply with the prepayment process for claims for all dates and services. Should you have any questions regarding the status of the suspension, please direct your inquiry to [shared mailbox]. Any request to remove the suspension must be submitted through the rebuttal process described above. Sincerely, Name C. Payment Suspension Initial Notice Based on Reliable Information (Prior Notice Given) Date Name of Addressee (if known) Name of Medicare Provider/Supplier Address City, State Zip Re: Notice of Suspension of Medicare Payments Provider/Supplier Medicare ID Number(s): Provider/Supplier NPI: PSP Number: Dear {Medicare Provider/Supplier’s Name}: The purpose of this letter is to notify you of our determination to suspend your Medicare payments {INSERT THE FOLLOWING IF THIS IS A NATIONAL PAYMENT SUSPENSION: in all jurisdictions} pursuant to 42 C.F.R. § 405.371(a)(1). The suspension of your Medicare payments will take effect on {ENTER DATE}. This payment suspension may last for up to 180 days from the effective date and may be extended under certain circumstances. See 42 C.F.R. § 405.372(d). The Centers for Medicare & Medicaid Services (CMS) through its Central Office made the decision to suspend your Medicare payments. See 42 C.F.R. § 405.372(a)(4)(iii). The suspension of your Medicare payments is based on reliable information that an overpayment exists or that the payments to be made may not be correct. Specifically, the suspension of your Medicare payments is based on, but not limited to, information from claims data analysis and medical review completed by {NAME OF UPIC or MAC}. More particularly, {Continue with further supportive information and specific claim examples (no less than five). Only use claim numbers, Date of Service and amount paid when referencing the claim examples. Do Not use beneficiary names or HIC#s in the notice.}. The following list of sample claims provide evidence of our findings and serve as a basis for the determination to suspend your Medicare payments: Claim Control Number Date(s) of Service $$ Amount Paid Basis for Selected Claim This list is not exhaustive or complete in any sense, as the investigation into this matter is continuing. The information is provided by way of example in order to furnish you with adequate notice of the basis for this payment suspension. Pursuant to 42 C.F.R. §§ 405.372(b)(2) and 405.374, you have the right to submit a rebuttal statement in writing to us within the next 15 days indicating why you believe the suspension should not be implemented or should be removed. If you opt to do so, you may include with this statement any evidence you believe is pertinent to your reasons why the suspension should not be implemented or should be removed. If you choose to submit a rebuttal statement, your rebuttal statement and any pertinent evidence should be sent to: {YOUR NAME}, Program Integrity Analyst {ADDRESS} If you submit a rebuttal statement, we will review that statement (and any supporting documentation) along with other materials associated with the case. Based on a careful review of the information you submit and all other relevant information known to us, we will determine whether the suspension should be implemented, removed, or should remain in effect within 15 days of receipt of the complete rebuttal package, consistent with 42 C.F.R. § 405.375. Thereafter, we will notify you in writing of our determination to implement, continue, or remove the suspension and provide specific findings on the conditions upon which the suspension may be implemented, continued, or removed, as well as an explanatory statement of the determination. See 42 C.F.R. § 405.375(b)(2). However, if by the end of this period no rebuttal has been received, the payment suspension will go into effect automatically. This determination is not an initial determination and is not appealable. See 42 C.F.R. § 405.375(c). If the suspension is implemented or continued, we will review additional evidence during the suspension period to determine whether claims are payable and/or whether an overpayment exists and, if so, the amount of the overpayment. See 42 C.F.R. § 405.372(c). We may need to contact you with specific requests for further information. We will inform you of developments and will promptly notify you of any overpayment determination(s). Claims will continue to be processed during the suspension period, and you will be notified about bill/claim determinations, including appeal rights regarding any bills/claims that are denied. The payment suspension also applies to claims in process. In the event that an overpayment is determined and it is determined that a recoupment of payments under 42 C.F.R. § 405.371(a)(3) should be put into effect, you will receive a separate written notice of the intention to recoup and the reasons. Please be advised that CMS may charge interest on the amount of the overpayment, consistent with 42 C.F.R. § 405.378. In the written notice alerting you to the overpayment, you will be given an opportunity for rebuttal in accordance with 42 C.F.R. § 405.374 from {MAC name}, CMS’ Medicare Administrative Contractor (MAC). When the payment suspension has been removed, any money withheld as a result of the payment suspension shall be applied first to reduce or eliminate any determined overpayment by CMS including any interest assessed under 42 C.F.R. § 405.378, and then to reduce any other obligation to CMS or to the U.S. Department of Health and Human Services in accordance with 42 C.F.R. § 405.372(e). In the absence of a legal requirement that the excess be paid to another entity, the excess will be released to you. {Insert the following paragraph if prepayment review is being initiated} Finally, {Name of UPIC or MAC}, a CMS {Unified Program Integrity Contractor (UPIC) or MAC}, has initiated a process to review your Medicare claims and supporting documentation prior to payment. The purpose of implementing this prepayment process is to ensure that all payments made by the Medicare program are appropriate and consistent with Medicare rules, regulations and policy. The prepayment process is often applied to safeguard Medicare from unnecessary expenditures and to ensure that Medicare payments are made for items and services which are “reasonable and necessary” for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. See 42 U.S.C. § 1395y(a)(1)(A). Notification is hereby given that you are expected to comply with the prepayment process for claims for all dates and services. Should you have any questions regarding the status of the suspension, please direct your inquiry to [shared mailbox]. Any request to remove the suspension must be submitted through the rebuttal process described above. Sincerely, Name D. Reliable Information that an Overpayment Exists (RIO) Payment Suspension Extension Notice Date Name of Addressee (if known) Name of Medicare Provider/Supplier Address City, State Zip Re: Notice of Extension of Suspension of Medicare Payments Provider/Supplier Medicare ID Number(s): Provider/Supplier NPI: PSP Number: Dear {Medicare Provider/Supplier’s Name}: Please be advised that pursuant to 42 C.F.R. § 405.372(d), the Centers for Medicare & Medicaid Services (CMS) has directed {ENTER UPIC NAME}, CMS’ Unified Program Integrity Contractor, to continue the suspension of your Medicare payments for an additional 180 days effective {Enter Date that the payment suspension was to expire}. The extension of your payment suspension applies to claims in process. We will continue to withhold your Medicare payments until an investigation of the circumstances has been completed in accordance with 42 C.F.R. § 405.372(d). When the payment suspension is terminated, any money withheld as a result of the payment suspension shall be applied first to reduce or eliminate any determined overpayment by CMS including any associated interest accrued pursuant to 42 C.F.R. § 405.378, and then to reduce any other obligation to CMS or the U.S. Department of Health and Human Services. See 42 C.F.R. § 405.372(e). In the absence of a legal requirement that the excess be paid to another entity, the remainder will be released to you. Should you have any questions regarding the status of the suspension, please direct your inquiry to [shared mailbox]. Sincerely, Name E. Credible Allegation of Fraud (CAF) Payment Suspension Extension Notice Date To: Attn: [Point of Contact] [Provider Name] [Provider Street Address] [Provider City, State Zip code] Reference Number: Provider Name: Provider Medicare ID Number (s): Provider NPI: Subject: Payment Suspension Extension Notice Dear [Point of Contact]: As previously advised in the Notice of Payment Suspension dated [date], the Centers for Medicare & Medicaid Services (CMS) suspended payments to [Provider/Supplier Name (“Shortened Name”)] based upon credible allegations of fraud under 42 C.F.R. § 405.371(a)(2). CMS regulations authorize payment suspensions based upon credible allegations of fraud to continue until resolution of the investigation including termination of any civil or criminal proceedings. See 42 C.F.R. § 405.370 (defining “resolution of an investigation”) and § 405.372(d)(3)(ii). Consistent with 42 C.F.R. § 405.371(b), CMS has (1) evaluated whether there is good cause to not continue the payment suspension and (2) received a certification from the Office of Inspector General (OIG) or other law enforcement agency that the matter continues to be under investigation warranting continuation of the suspension. We are writing to inform you that the payment suspension remains in place. The maintenance of your payment suspension applies to claims in process. When the payment suspension is terminated, any money withheld as a result of the payment suspension shall be applied first to reduce or eliminate any determined overpayment by CMS including any interest assessed under 42 C.F.R. § 405.378, and then to reduce any other obligation to CMS or the U.S. Department of Health and Human Services. See 42 C.F.R. § 405.372(e). In the absence of a legal requirement that the excess be paid to another entity, the excess will be released to you. Should you have any questions regarding the status of the suspension, please direct your inquiry to [UPIC Email address]. Sincerely, [UPIC PoC] Program Integrity Manager [Region] Unified Program Integrity Contractor [Name of UPIC] [Telephone] F. Payment Suspension Termination Notice USE THIS LETTER IF SENDING PAYMENT SUSPENSION TERMINATION NOTICE TO THE PROVIDER’S/SUPPLIER’S ATTORNEY Date Name of Attorney Address City, State Zip Re:Notice of Commencement of Process for Termination of Suspension of Medicare Payments Provider/Supplier Medicare ID Number(s): Provider/Supplier NPI: Record Identifier(s): Dear {Medicare Provider/Supplier Attorney’s Name}: The Centers for Medicare & Medicaid Services (CMS) has directed us to commence the process to terminate the payment suspension in effect for Medicare payments to [provider] pursuant to 42 C.F.R. § 405.372(c). The provider was notified of the results of our review and the overpayment(s) we determined on [INSERT DATE]. The overpayment information was forwarded to [INSERT MAC], CMS’ Medicare Administrative Contractor (MAC) for further action. As part of that process, the MAC will review our findings and will issue the overpayment demand letter(s), along with information regarding the provider’s appeal rights. The MAC typically will complete the process to terminate the suspension within approximately 60 days. Once the payment suspension is terminated, any funds withheld as a result of the payment suspension shall be applied first to reduce or eliminate any overpayments determined by CMS including any associated interest accrued pursuant to 42 C.F.R. § 405.378 and then to reduce any other obligation to CMS or the U.S. Department of Health and Human Services per 42 C.F.R. § 405.372(e). In the absence of a legal requirement that the excess be paid to another entity, the excess will be released to the provider. Please be advised that the termination of the payment suspension should not be construed as a positive determination regarding the provider’s Medicare billing and is not an indication of government approval of or acquiescence regarding the claims submitted. It does not relieve the provider of any civil or criminal liability, and it does not offer a defense to any further administrative, civil or criminal actions against the provider. Sincerely, Name G. Payment Suspension Termination Notice USE THIS LETTER IF SENDING PAYMENT SUSPENSION TERMINATION NOTICE TO THE PROVIDER/SUPPLIER Date Name of Addressee (if known) Name of Medicare Provider/Supplier Address City, State Zip Re:Notice of Commencement of Process for Termination of Suspension of Medicare Payments Provider/Supplier Medicare ID Number(s): Provider/Supplier NPI: Record Identifier(s): Dear {Medicare Provider/Supplier’s Name}: The Centers for Medicare & Medicaid Services (CMS) has directed us to commence the process to terminate the payment suspension in effect for Medicare payments to [provider] pursuant to 42 C.F.R. § 405.372(c). You were notified of the results of our review and the overpayment(s) we determined on [INSERT DATE]. The overpayment information was forwarded to [INSERT MAC], CMS’ Medicare Administrative Contractor (MAC), for further action. As part of that process, the MAC will review our findings and issue the overpayment demand letter(s), along with information regarding your appeal rights. Typically, the MAC will complete the process to terminate the suspension within approximately 60 days. Once the payment suspension is removed, any funds withheld as a result of the payment suspension shall be applied first to reduce or eliminate any overpayments determined by CMS including any associated interest accrued pursuant to 42 C.F.R. § 405.378 and then to reduce any obligation to CMS or the U.S. Department of Health and Human Services per 42 C.F.R. § 405.372(e). In the absence of a legal requirement that the excess be paid to another entity, the excess will be released to you. Please be advised that the termination of a payment suspension should not be construed as any positive determination regarding your Medicare billing and is not an indication of government approval of or acquiescence regarding the claims submitted. It does not relieve you of any civil or criminal liability, and it does not offer a defense to any further administrative, civil or criminal actions against you. Sincerely, Name