CMS Approval

8.3.2.1 – CMS Approval (Rev.: 13762; Issued: 05-27-26 ; Effective: 06-29-26 ; Implementation: 06-29-26) If the UPIC believes that a UPIC-initiated Payment Suspension is a viable option for an investigation, they shall update UCM appropriately to ensure the case is included on the next case coordination meeting agenda for discussion. For national or multi-regional suspensions, only the lead UPIC shall discuss the suspension at the case coordination meeting. During the case coordination meeting, if CMS agrees that the criteria for Payment Suspension is met, CMS will instruct the UPIC to submit the Payment Suspension recommendation(s) with the completed AAR form to CPI through the UCM. The Payment Suspension team member will review the submissions and make a formal determination as to whether a Payment Suspension is a viable option. During the case coordination meeting, the UPIC may receive additional guidance from CMS related to subsequent actions related to these investigations. If the UPIC has questions following the case coordination meeting, the UPIC shall coordinate with its COR, BFL, and/or suspension team member, as needed. When a payment suspension is approved by CPI, the UPIC shall inform the respective MAC of this action and the MAC shall effectuate the suspension of payments to the provider unless prior notice of the payment suspension is necessary. When prior notice is necessary, the MAC shall effectuate the suspension of payment in concert with the established date from the payment suspension notice. For all payment suspensions, the UPIC shall request the MAC implement a “payment suspension” or “partial payment suspension” when applicable. For all payment suspensions and emergency payment suspensions, the MAC shall no longer use "F_Fraud and Abuse", “F_CMS Request” or “P_CMS Request” HIGLAS hold reason codes for UPIC requested payment suspension activities. MACs shall only use "F_PSC Request" (Full Hold) or “P_PSC Request”(Partial Hold) HIGLAS hold reason codes going forward for all UPIC requested payment suspension and emergency payment suspension activities. UPICs shall not request that MACs create placeholder debts or “escrow amounts” based on anticipated provider settlements. The MAC shall no longer create these debts in HIGLAS. If a UPIC requests a MAC to create a placeholder debt, the MAC shall reach out to OFM for guidance before any action is taken. The MACs shall ensure that all money on the payment floor is not released to the provider after the effective date of the suspension and the money is withheld in accordance with the payment suspension rules and regulations. MACs shall provide an accounting of the money withheld on day one of the payment suspension to the UPIC. The UPIC shall enter this amount in the UCM as the first monetary entry. Unless otherwise specified, when a payment suspension is imposed, no payments are to be released to the provider as of the effective date of the payment suspension. This includes payments for new claims processed, payments for adjustments to claims previously paid, interim PIPs. If it is discovered that money is released to the provider after the effective date of the payment suspension, the MAC or UPIC shall contact CPI for guidance.