Suspension of Payment

8.3 – Suspension of Payment (Rev. 12127; Issued: 07-21-23; Effective: 08-21-23; Implementation: 08-21-23) This section applies to Medicare Administrative Contractors (MACs) and Unified Program Integrity Contractors (UPICs). Hereinafter, suspension of payment may be referenced as “payment suspension.” Requests for Suspension of Payment (“Payment Suspension”) may be approved when there is reliable information that an overpayment exists, when payments to be made may not be correct, or when there is a credible allegation of fraud existing against a provider. The process by which the UPIC notifies and coordinates with the MAC to implement a CMS-approved suspension of payment shall be documented in the Joint Operating Agreement (JOA) between the MAC and the UPIC. The UPICs shall advise and coordinate the imposition of a payment suspension with the appropriate MAC when a payment suspension has been approved by CMS. The UPIC shall perform the necessary medical review and development of overpayments for payment suspensions that have received CMS approval, when appropriate. Medicare authority to withhold payment in whole or in part for claims otherwise determined to be payable is found in federal regulations at 42 CFR §405.370-375, which provide for the suspension of payments. All payment suspensions shall be referred to the CMS/Center for Program Integrity (CPI) via the Unified Case Management System (UCM) for approval. UPICs shall notify their appropriate CPI Business Function Lead (BFL), with a copy to the Contracting Officer’s Representative (COR), of the submission by providing the UCM number via email.