Duration of the Payment Suspension

8.3.2.4 – Duration of the Payment Suspension (Rev. 13762; Issued: 05-27-26; Effective: 06-29-26; Implementation: 06-29-26) A. Time Limits for General Suspensions If CPI approves a general suspension, it will be for a 180 calendar day period. The UPIC shall complete its medical review and any subsequent activities (i.e., statistical sampling extrapolation, draft overpayment determination notice, etc.) during the initial 180 days of a general suspension. CMS expects the medical reviews to be completed and the calculation of any potential overpayments to be determined before the end of the initial suspension period. Only in rare instances will an extension be granted. If an extension is required, the UPIC shall request an extension of an additional 180 calendar days if time is needed to complete the overpayment determination. Only CPI may approve the request to extend the period of the payment suspension for up to an additional 180 calendar days upon the written request of the UPIC. The request to CPI to extend the payment suspension shall provide the following: • Completion of the “Extension Recommendation Information” section of the AAR. A draft of the proposed payment suspension extension notice following the format noted in section 8.3.2.2 of this chapter (in a word document format); • A timeline of the completion of the medical review; and • Any other supporting documentation. If approved for an extension, the period of time shall not exceed 180 calendar days. General suspensions shall not continue beyond 360 calendar days. However, there may be an occasion when the information gathered by the UPIC during its review supports a change from a general suspension to a fraud suspension. Only with CPI approval may the category of the type of payment suspension be transitioned from a general payment suspension to a fraud suspension. If the transition from a general payment suspension to a fraud payment suspension is approved, the provider must be informed of the new development by the UPIC with a CPI-approved notice. Additionally, the provider must be afforded the opportunity for rebuttal. B. Exceptions to Time Limits for Fraud Suspensions If a payment suspension is based on credible allegations of fraud, the payment suspension may continue beyond 360 days with a written request for an extension from law enforcement. An extension may be warranted if there has not been a resolution of law enforcement’s investigation of the potential fraud. After 18 months, good cause not to continue a payment suspension is deemed to exist unless certain criteria are satisfied. (See 42 C.F.R. §405.371(b)(3).) To extend a fraud suspension beyond 18 months: • The Department of Justice must submit a written request for an extension. Requests must include: 1) the identity of the person or entity under the payment suspension, 2) the amount of time needed for continuation of the payment suspension in order to conclude the criminal or civil proceeding or both, and 3) a statement of why and/or how criminal and/or civil actions may be affected if the payment suspension is not granted. • The OIG must submit a written request to extend the payment suspension because the case is being considered by the OIG for an administrative action (e.g., permissive exclusions, CMPs) or such action is pending. However, this exception does not apply to pending criminal investigations by OIG. C. Provider Notice of the Extension The UPIC shall obtain CPI approval for the extension request and draft notice, and shall notify the provider if the suspension action has been extended. The UPIC shall prepare a “draft extension notice” (in accordance with section 8.3.2.2 of this chapter) and submit it via the UCM, along with any other supportive information, to CPI for approval 30 calendar days prior to the suspension’s expiration date (limited early submissions are acceptable based on operational realities). If the 30th day falls on a non-business day, the UPIC shall submit the request on the next business day. The draft notice shall follow the model language provided in the exhibits and shall include, at a minimum: • The date the payment suspension will be extended (NOTE: The date is to be the same date the payment suspension was to expire); • The reason for extending the payment suspension; and • That CMS has approved the extension of the payment suspension. Upon approval of the notice from CPI, the UPIC shall provide a copy of the signed notice to CPI via the UCM.