Provider Fails to Furnish Records and Other Requested

8.3.1.4 – Provider Fails to Furnish Records and Other Requested Information - General Suspensions (Rev. 13762; Issued: 05-27-26; Effective: 06-29-26; Implementation: 06-29-26) A payment suspension may be used when the MAC, UPIC, or CMS possesses reliable information that the provider has failed to furnish records and other information requested or that is due, and which is needed to determine the amounts due the provider. 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): During a post-payment review, medical records and other supporting documentation are solicited from the provider to support payment. The provider fails to submit the requested records after two attempts. The UPIC may request a payment suspension due to non-response from the provider. In lieu of imposing a payment suspension, the MAC or UPIC may deny the paid claims because the provider failed to provide the requested documentation after two attempts. In either case, the MAC or UPIC should determine if the provider is continuing to submit claims for the services in question and take appropriate action(s) to correct the behavior. NOTE: In the above example, if the only reason for the payment suspension is the failure by the provider to furnish the requested records, and if the provider does eventually provide the requested information, the UPIC shall discuss this matter with CPI for guidance. EXAMPLE (including but not limited to): The provider fails to timely file an acceptable cost report. Refer to 42 CFR §405.371(d). (NOTE: Such requests regarding the timely filing of an acceptable cost report shall be submitted only to and approved by the CMS, Office of Financial Management and not CPI.)