Reliable Information that an Overpayment Exists - General

8.3.1.2 – Reliable Information that an Overpayment Exists - General Suspensions (Rev. 13762; Issued: 05-27-26; Effective: 06-29-26; Implementation: 06-29-26) A payment suspension may be implemented when the MAC, UPIC, or CMS possesses reliable information that an overpayment exists. In this situation, the MAC shall refer its information to the respective UPIC for development of a potential suspension. If warranted, the UPIC shall complete the payment suspension AAR and submit the payment suspension recommendation via the UCM. The AAR shall serve as the UPIC’s documented recommendation for CMS’ consideration of a payment suspension and, when completed, include the UPIC’s findings and all pertinent provider/supplier information. The AAR, draft notice of suspension, and all other relevant documentation that supports the suspension recommendation shall be uploaded by the contractor as part of the UCM submission. For the purposes of this section, these types of payment suspensions will be called “general suspensions.” EXAMPLE (including but not limited to): Several claimed services identified from either a prepayment or post-payment review were determined to be non-covered or miscoded. It has been determined that there is a pattern of noncompliant billings (the provider has billed this service many times before) and it is suspected that there may be a substantial number of additional non-covered or miscoded claims paid in the past.