Medicare Program Integrity Manual 
Chapter 1 - Medicare Improper Payments: Measuring, 
Correcting, and Preventing Overpayments and 
Underpayments 
 
Table of Contents  
(Rev. 11032, 09-30-21) 
 
Transmittals for Chapter 1 
 
1.1- Overview of Program Integrity and Provider Compliance 
1.2 - Definitions 
1.3 - Medicare Improper Payment Reduction Efforts  Provider Compliance 
1.3.1  Types of Contractors 
1.3.2  Improper Payment Prevention Goals 
1.3.3  Applicable of Problem Integrity Manual Sections 
1.3.4  Performance Metrics 
1.3.5  Types of Claims for Which Contractors Are Responsible 
1.3.6  Quality of Care Issues and Potential Fraud Issues 
1.3.7  The MAC and SMRC Medical Review Program 
1.3.8  Goal of MAC and SMRC MR Program 
1.3.9  Provider Self Audits 
1.3.10  Coordination Among Contractors 
1.4 - Contractor Medical Director (CMD) 
1.5 - Medical Review Manager 
1.6  Maintaining the Confidentiality of MR Medical Records and Documents 
1.7  Benefit Integrity 
1.8  Medical Review for Benefit Integrity (MR for BI) 
  1.1- Overview of Program Integrity and Provider Compliance 
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
The term Review Contractor throughout the Program Integrity Manual refers to: 
 
  Medicare Administrative Contractors (MACs) 
  Comprehensive Error Rate Testing (CERT) contractors 
  Recovery Auditors 
  Unified Program Integrity Contractors (UPICs) 
  Supplemental Medical Review Contractor (SMRC) 
 
Review Contractors shall follow all sections of the PIM unless otherwise indicated as 
required by their applicable Statements of Work (SOW). 
 
1.2 - Definitions 
(Rev. 313; Issued:  11-20-09; Effective/Implementation Date:  12-21-09) 
 
To facilitate understanding, the terms used in the PIM are defined in Exhibit 1. 
 
1.3  Medicare Improper Payment Reduction Efforts  Provider 
Compliance 
(Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14) 
 
The Centers for Medicare & Medicaid Services (CMS) is the Federal agency that 
operates the Medicare program.  Addressing improper payments in the Medicare fee-for-
service (FFS) program and promoting compliance with Medicare coverage and coding 
rules is a top priority for the CMS.  Preventing Medicare improper payments requires the 
active involvement of every component of CMS and effective coordination with its 
partners including various Medicare contractors and providers.  The CMS contracts with 
various types of contractors in its effort to fight improper payments and promote provider 
compliance in the Medicare FFS program:  
 
  CERT contractors;  
  MACs; 
  Recovery auditors; and 
  SMRC. 
 
1.3.1 - Types of Contractors 
(Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14) 
 
A.  CERT Contractors 
 
The CMS implemented the CERT program which establishes error rates and estimates of 
improper payments that is compliant with the Improper Payments Elimination and 
Recovery Improvement Act (IPERIA). 
 
B. MACs   
The MACs primarily use error rates produced by the CERT program and vulnerabilities 
identified through the Recovery Audit program to identify where to target their improper 
payment prevention efforts.  The MACs analyze their internal data to determine which 
corrective actions would be best to prevent the CERT-identified and Recovery Auditor-
identified vulnerabilities in the future.  The CMS has determined that most improper 
payments in the Medicare FFS program occur because a provider did not comply with 
Medicares coverage, coding, or billing rules.  The cornerstone of the MACs efforts to 
prevent improper payments is each contractors Error Rate Reduction Plan (ERRP), 
which includes initiatives to help providers comply with the rules. These initiatives 
usually fall into one of three categories:  
 
1.  Targeted provider education to items or services with the highest improper 
payments, 
 
2.  Prepayment and postpayment claim review targeted to those services with the 
highest improper payments.   In addition, in order to encourage providers to 
submit claims correctly, MACs can perform extrapolation reviews as needed, and  
 
3.  New or revised local coverage determinations, articles or coding instructions to 
assist providers in understanding how to correctly submit claims and under what 
circumstances the services will be considered reasonable and necessary. 
 
See section 1.3.6, for information on quality of care and potential fraud issues. 
 
C. Recovery Auditors 
 
Although CMS, through the MACs have undertaken actions to prevent future improper 
payments, it is difficult to prevent all improper payments, considering that the Medicare 
FFS program processes more than 1 billion claims each year.  The CMS uses the 
Recovery Audit program to detect and correct improper payments in the Medicare FFS 
program and provide information to CMS and review contractors that could help protect 
the Medicare Trust Funds by preventing future improper payments. 
 
D. Supplemental MR Contractor (SMRC) 
 
The Supplemental Medical Review Contractors (SMRC) main tasks are to perform 
and/or provide support for a variety of tasks aimed at lowering the improper payment 
rates and increasing efficiencies of the medical review functions of the Medicare and 
Medicaid programs. Having a centralized medical review (MR) resource that can perform 
large volume MR nationally allows for a timely and consistent execution of MR review, 
activities and decisions. The focus of the reviews may include but are not limited to 
issues identified by CMS internal data analysis, the CERT program, professional 
organizations and other Federal agencies, such as the OIG/GAO and comparative billing 
reports. 
 
1.3.2 - Improper Payment Prevention Goals 
(Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14) 
  The CMS strives in every case to pay the right amount to a legitimate provider, for 
covered, correctly coded and correctly billed services, provided to an eligible beneficiary.  
To achieve the goal of improving provider compliance and lowering the error rate, CMS 
follows three parallel strategies:  
 
  Preventing improper payments through MACs and SMRC evaluation of program 
vulnerabilities and taking the necessary action to prevent the identified 
vulnerabilities in the future 
 
  Correcting past improper payments through postpayment claim review by the 
Recovery Auditors 
 
  Measuring improper payments and pinpointing the causes of improper payments 
by calculating service specific, provider type and contractor specific error rates by 
the CERT contractors 
 
1.3.3 - Applicable Program Integrity Manual Sections 
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
  The MACs, CERT, Recovery Auditors, UPICs, and SMRC shall follow all 
sections of the PIM unless otherwise indicated 
 
  The MACs, CERT, Recovery Auditors, UPICs and SMRC shall follow the 
PIM to the extent outlined in their SOWs. 
 
1.3.4 - Performance Metrics 
(Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14) 
 
A.  MAC MR Units Performance 
 
The MAC MR Unit performance is measured by: 
 
  CERT:  CERT is a CMS program that measures a contractors payment error 
rate. 
 
  In addition, the MACs are measured by other measures listed in the MAC SOW. 
 
B.  Recovery Auditor Performance: 
 
One key measure of Recovery Auditor performance is the Recovery Auditor accuracy 
rate.  CMS will produce a Recovery Auditor accuracy rate for each Recovery Auditor on 
an annual basis.  These rates will be released to the public through the annual Report to 
Congress. 
 
C.  CERT Performance 
 
The CERT performance metrics are listed in the contractors SOW.  One key measure of 
CERT performance is the timely production of the national error rate each year.   
D. SMRC 
 
A performance measure of the SMRC contractor is the accuracy rate. This will be 
coordinated by CMS annually. Additional performance measures are listed in their SOW. 
 
1.3.5 - Types of Claims for Which Contractors Are Responsible 
(Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14) 
 
A.  MACs 
 
The MACs should, at their discretion perform medical review functions for all claims 
appropriately submitted to them. 
 
Although they will continue to perform a number of quality functions, quality 
improvement organizations (QIOs) will no longer be performing the majority of 
utilization reviews for acute inpatient prospective payment system (IPPS) hospital and 
long-term care hospital (LTCH) claims.  The review of acute IPPS hospital and LTCH 
claims (which, for the purposes of this section, also includes claims from any hospital 
that would be subject to the IPPS or LTCH PPS had it not been granted a waiver) is now 
the responsibility of the ACs and MACs.  An exception occurs when a provider requests 
a higher-weighted diagnosis related group (DRG) review from the QIO.  The QIO will 
continue to perform those reviews.  QIOs will also continue to perform reviews related to 
quality of care and expedited determinations. 
 
The MACs shall include claims for which they are responsible when performing data 
analysis to plan their medical review strategy.  Amendments to plans and strategies shall 
be made as needed if analysis indicates adjustment of priorities. 
 
B.  CERT 
 
The CERT review contractor is responsible for reviewing claims randomly selected by 
the CERT statistical contractor. 
 
C.  Recovery Auditors 
 
In general, Recovery Auditors are responsible for reviewing claims where improper 
payments have been made or there is a high probability that improper payments were 
made. 
 
D. SMRC 
 
Medical review will be performed on Part A, Part B, and DME providers and suppliers as 
directed by CMS. 
 
 
 
  1.3.6 - Quality of Care Issues and Potential Fraud Issues 
(Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) 
 
Potential quality of care issues are not the responsibility of the MAC, CERT or Recovery 
Auditor, UPIC, and SMRC but they are the responsibility of the QIO, State 
licensing/survey and certification agency, or other appropriate entity in the service area. 
MACs, CERT, Recovery Auditor, UPICs and SMRC shall refer quality of care issues to 
the QIO, State licensing/survey and certification agency, or other appropriate entity in the 
service area. See chapter 3, section 3.1, for a discussion of how contractors should handle 
situations where providers are non-compliant with Medicare conditions of participation. 
 
Contractors shall analyze provider compliance with Medicare coverage and coding rules 
and take appropriate corrective action when providers are found to be non-compliant. For 
repeated infractions, or infractions showing potential fraud or pattern of abuse, more 
severe administrative action shall be initiated. At any time, evidence of fraud shall result 
in referral to the UPICs for development. See chapter 4, section 4.9.4.2 for a discussion 
on benefit integrity interaction with QIOs. 
 
 
1.3.7 - The MAC and SMRC Medical Review Program 
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
The MR program is designed to prevent improper payments in the Medicare FFS 
program. Whenever possible, MACs are encouraged to automate this process; however 
it may require the evaluation of medical records and related documents to determine 
whether Medicare claims were billed in compliance with coverage, coding, payment, 
and billing policies. 
 
The statutory authority for the MR program includes the following sections of the 
Social Security Act (the Act): 
 
  Section 1833(e) which states, in part "...no payment shall be made to any 
provider... unless there has been furnished such information as may be 
necessary in order to determine the amounts due such provider ...;" 
 
  Section 1842(a)(2)(B) which requires ACs and MACs to "assist in the 
application of safeguards against unnecessary utilization of services furnished 
by providers 
...; " 
 
  Section 1862(a)(1) which states no Medicare payment shall be made for 
expenses incurred for items or services that "are not reasonable and necessary 
for the diagnosis or treatment of illness or injury or to improve the functioning 
of a malformed body member;" 
 
  The remainder of Section 1862(a) which describes all statutory exclusions 
from coverage; 
    Section 1893(b)(1) establishes the Medicare Integrity Program which allows 
contractors to review activities of providers of services or other individuals and 
entities furnishing items and services for which payment may be made under 
this title (including skilled nursing facilities and home health agencies), 
including medical and utilization review and fraud review (employing similar 
standards, processes, and technologies used by private health plans, including 
equipment and software technologies which surpass the capability of the 
equipment and technologies. . . 
 
  Sections 1812, 1861, and 1832 which describe the Medicare benefit 
categories; and 
 
  Sections 1874, 1816, and 1842 which provide further authority. 
 
The regulatory authority for the MR program rests in: 
 
  42 CFR 421.100 for intermediaries. 
  42 CFR 421.200 for carriers. 
  42 CFR 421.400 for MACs. 
 
The UPICs shall refer to chapter 4 for MR for BI purposes. 
 
1.3.8 - Goal of MAC and SMRC MR Program 
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
The  goal  of  the  MAC  and  SMRC  MR  program  is  to  reduce  payment  error  by 
preventing the initial payment of claims that do not comply with Medicares with 
coverage, coding, payment, and billing policies. To achieve the goal of the MR 
program, 
 
MACs: 
 
  Identify provider noncompliance with coverage, coding, billing, and 
payment policies through analysis of data. (e.g., profiling of providers, 
services, or beneficiary utilization) and evaluation of other information 
(e.g., complaints, enrollment and/or cost report data). (Chapter 2 describes 
these activities in further detail.); 
 
  Take action to prevent and/or address the identified improper payment; (chapter 
3, describes these actions in further detail.); and 
 
  Place emphasis on reducing the paid claims error rate by notifying the 
individual billing entities (i.e., providers, suppliers, or other approved 
clinician) of review findings identified by the ACs or by the MACs and 
making appropriate referrals to provider outreach and education (POE), and 
UPICs. 
 
SMRC:    Identify provider noncompliance with coverage, coding, billing, and payment 
policies through the research and analysis of data related to assigned task. 
(e.g., profiling of providers, services, or beneficiary utilization) 
 
  As directed by CMS, perform medical review 
 
  As directed by CMS, perform extrapolation 
 
  Notify the individual billing entities (i.e., providers, suppliers, or other 
approved clinician) of review findings identified and make appropriate 
recommendations for POE and UPIC referrals 
 
1.3.9  Provider Self Audits 
(Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) 
 
Providers may conduct self-audits to identify coverage and coding errors. The Office of 
Inspector General (OIG) Compliance Program Guidelines can be found at 
https://oig.hhs.gov/compliance/compliance-guidance/index.asp and the statistical 
guidelines in https://oig.hhs.gov/authorities/docs/selfdisclosure.pdf (if statistical 
sampling is utilized during the audit).  The MACs shall follow chapter 4, section 
4.2.2.8.1.3, handling any voluntary refunds that may result from these provider self-
audits. 
 
Most errors do not represent fraud. Most errors are not acts that were committed 
knowingly, willfully, and intentionally. However, in situations where a provider has 
repeatedly submitted claims in error, the MACs shall follow the procedures listed in 
chapter 3, section 3.2.1. For example, some errors will be the result of provider 
misunderstanding or failure to pay adequate attention to Medicare policy. Other errors 
will represent calculated plans to knowingly acquire unwarranted payment. Per chapter 4, 
section 4.2.1, MACs shall take action commensurate with errors made. The MACs shall 
evaluate the circumstances surrounding the errors and proceed with the appropriate plan 
of correction. 
 
1.3.10  Coordination Among Contractors 
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
A.  Coordination among MACs and UPICs 
 
The MAC MR staff shall coordinate and communicate with their associated UPIC to 
ensure coordination of efforts and to prevent inappropriate duplication of review 
activities. At any time, suspicion of fraud should result in referral to the UPIC for 
development. 
 
B.  Coordination among MACs and the Recovery Auditors 
 
See Pub. 100-06, Financial Management Manual, chapter 4, section 100.1-100.15, for 
a description of the coordination efforts between MACs and Recovery Auditors. In 
addition, the MACs shall coordinate and communicate with the Recovery Auditors to  get the specifics on Recovery Auditor identified vulnerabilities for use in the MACs 
data analysis and possible corrective actions. 
 
C.  SMRC 
 
The SMRC shall make all recommendations for referrals through their CMS 
Contract Officer Representative (COR). 
 
1.4 - Contractor Medical Director (CMD) 
(Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14) 
 
 MACs: 
 
The MACs shall employ a minimum of two FTEs contractor medical director (CMD) and 
arrange for an alternate when the CMD is unavailable for extended periods. The CMD 
FTEs shall be composed of either a Doctor of Medicine or a Doctor of Osteopathy. All 
clinicians employed or retained as consultants shall be currently licensed to practice 
medicine in the United States, and the contractor shall periodically verify that the license 
is current. When recruiting CMDs, contractors shall give preference to physicians who 
have patient care experience and are actively involved in the practice of medicine. The 
CMD's duties are listed below. 
 
Primary duties include: 
 
  Leadership in the provider community, including: 
 
  Interacting with medical societies and peer groups; 
o
 
  Educating providers, individually or as a group, regarding identified problems 
o
or LCDs; and  
 
  Acting as co-chair of the Contractor Advisory Committee (CAC) (see chapter 
o
13 13.8.1.4 of this manual for co-chair responsibilities). 
 
  Providing the clinical expertise and judgment to develop LCDs and internal MR 
guidelines: 
 
  Serving as a readily available source of medical information to provide 
o
guidance in questionable claims review situations; 
 
  Determining when LCDs are needed or must be revised to address program 
o
abuse; 
 
  Assuring that LCDs and associated internal guidelines are appropriate; 
o
 
  Briefing and directing personnel on the correct application of policy during 
o
claim adjudication, including through written internal claim review 
guidelines;   
  Selecting consultants licensed in the pertinent fields of medicine for expert 
o
input into the development of LCDs and internal guidelines; 
 
  Keeping abreast of medical practice and technology changes that may result in 
o
improper billing or program abuse; 
 
  Providing the clinical expertise and judgment to effectively focus MR on 
o
areas of potential fraud and abuse; and 
 
  Serving as a readily available source of medical information to provide 
o
guidance in questionable situations. 
 
Other duties include: 
 
  Interacting with the CMDs at other contractors to share information on potential 
problem areas; 
 
  Participating in CMD clinical workgroups, as appropriate; and  
 
Upon request, providing input to CO on national coverage and payment policy, including 
recommendations for relative value unit (RVU) assignments. 
 
SMRC: 
 
Primary duties include: 
 
  Serving as a readily available source of medical information to provide guidance 
in questionable claims review situations 
 
  Providing the clinical expertise and judgment to develop LCDs and internal MR 
guidelines 
 
  Keeping abreast of medical practice and technology changes that may result in 
improper billing or program abuse 
 
  Providing clinical expertise and judgment to effectively focus MR on areas of 
potential fraud and abuse 
 
  Serving as a readily available source of medical information to provide guidance 
in questionable situations 
 
1.5 - Medical Review Manager 
(Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14) 
 
MACs: 
  An effective MR program begins with the strategies developed and implemented by 
senior management staff. The MACs shall name an MR point of contact referred to as the 
MR Manager who will act as the primary contact between the contractor and CMS 
concerning the contractor's MR program. The MR Manager will also have primary 
responsibility for the development, oversight and implementation of the contractors MR 
Strategy, SAR, and quality assurance process. In addition, the MR Manager shall have 
the primary responsibility for ensuring the timely submission of required reports. 
 
SMRC: 
 
An effective Medical Review program begins with the senior management staff. The 
Contractor shall name a Medical Review point of contact referred to as the Medical 
Review Manager who will act as the primary contact between the Contractor and CMS 
concerning the SMRC medical review program. The MR Manager will also have primary 
responsibility for development, oversight and implementation of the Contractors quality 
assurance process. In addition, the MR Manager shall have the primary responsibility for 
ensuring the timely submission of required reports. The MR Manager shall be a 
registered nurse. The MR Manager shall work collaboratively with their Project Manager 
and Contract Medical Director to plan, implement and evaluate all MR projects/tasks 
directed by CMS. 
 
1.6  Maintaining the Confidentiality of MR Medical Records and 
Documents 
(Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14) 
 
A.  Contractors to Which This Section Applies 
 
This section applies to MACs, CERT, Recovery Auditors, and SMRC. 
 
B.  General 
 
Contractors shall maintain the confidentiality of all MR medical records and documents 
before, during, and after the MR process. Similarly, contractors that use a 
subcontractor(s) to perform MR, to store MR documents, and/or to transport MR 
documents, are responsible for ensuring that the subcontractor(s) maintains the 
confidentiality of the MR documents that it handles. This responsibility applies to all 
contact with these documents by all parties and entities, however derived from the 
contractor. The responsibility is not limited or ended if the subcontractor allows an 
additional party or entity to have contact with these documents. Thus, just as the 
contractor shall assure that the subcontractor maintain confidentiality itself, so too shall 
the contractor assure that the subcontractor similarly assures that any third party or other 
entity, such as a sub to the subcontractor, which has contact with the documents, maintain 
confidentiality. 
 
1.7 - Benefit Integrity 
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
A.  Contractors to Which This Section Applies   
This section applies to UPICs only. 
 
B.  General 
 
In addition to reducing improper payments, CMS strives to protect the program 
from potential fraud. CMS contracts with Unified Program Integrity Contractors 
(UPICs) to identify and stop potential fraud. 
 
The primary task of UPICs is to identify cases of suspected fraud, develop them 
thoroughly and in a timely manner, and take immediate action to ensure that Medicare 
Trust Fund monies are not inappropriately paid out and that any mistaken payments are 
identified. UPICs shall refer cases of potential fraud to the Department of Health and 
Human Services (HHS) Office of Inspector General (OIG) Office of Investigations 
(OI). 
 
1.8 - Medical Review for Benefit Integrity (MR for BI) 
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
A.  Contractors to Which This Section Applies 
 
This section applies to UPICs. 
 
B.  General 
 
The goal of the MR for BI program is to address situations of potential fraud, waste, 
and abuse (e.g., looking for possible falsification). 
 
Information on maintaining the confidentiality of MR documents can be found in 
this chapter, section 1.6. 
    Transmittals Issued for this Chapter 
 
Rev #  Issue Date  Subject  Impl Date  CR# 
R11032PI 09/30/2021  Updates to Chapters 1, 3, 4, 5, 8 and 9 of  11/10/2021 12375 
Publication (Pub.) 100-08 
R10984PI 09/09/2021  Updates to Chapters 1, 3, 4, 5, 8 and 9 of  11/10/2021 12375 
Publication (Pub.) 100-08 - Rescinded and 
replaced by Transmittal 11032 
R10365PI 10/02/2020  Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8, 10,  08/27/2020 11884 
11, and Exhibits of Publication (Pub.) 100-08-  
R10228PI 07/27/2020  Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8, 10,  08/27/2020 11884 
11, and Exhibits of Publication (Pub.) 100-08 
Rescinded and Replaced by Transmittal 
10365 
R508PI  03/07/2014  Supplemental Medical Review Contractor  04/08/2014 8578 
R454PI  03/14/2013  Minor Changes to Chapter 1 of the Program  04/01/2013 8205 
Integrity Manual 
R451PI  03/01/2013  Minor Changes to Chapter 1 of the Program  04/01/2013 8205 
Integrity Manual  Rescinded and replaced by 
Transmittal 454 
R448PI  01/31/2013  Deletion of MR Operations Mailbox  03/04/2013 8187 
R425PI  06/15/2012  Provider Self Audits  07/16/2012 7851 
R313PI  11/20/2009  Program Integrity Manual (PIM)  12/21/2009 6546 
Reorganization Chapters 1, 2, and 7 
R264PI  08/07/2008  Transition of Responsibility for Medical  08/15/2008 5849 
Review From Quality Improvement 
Organizations (QIOs) 
R229PI  11/23/2007  Medical Review Strategy and Strategy  04/07/2008 5760 
Analysis Report 
R220PI  08/24/2007  Various Medical Review Clarifications  09/03/2007 5550 
R203PI  05/25/2007  Strategy Analysis Report  07/02/2007 5519 
R174PI  11/17/2006  Transition of Medical Review Educational  10/06/2006 5275 
Activities 
R170PI  11/03/2006  Transition of Medical Review Educational  10/06/2006 5275 
Activities 
R163PI  09/29/2006  Transition of Medical Review Educational  10/06/2006 5275 
Activities 
R136PI  02/01/2006  Contractor Medical Director Requirements  03/01/2006 4105 
R118PI  08/12/2005  Various Benefit Integrity (BI) Clarifications  09/12/2005 3896 
R107PI  04/08/2005  Updated Chapter 1 to Reflect Changes in  05/09/2005 3754 
Program Requirements  R099PI  01/21/2005  Waivers Approved by the Regional Office  02/22/2005 3646 
(RO) by Replacing Regional Office with 
Central Office (CO) 
R071PI  04/09/2004  Rewrite of Program Integrity Manual (except  05/10/2004 3030 
Chapter 10) to Apply to PSCs 
R065PI  01/30/2004  Requirement Removal of Fiscal Intermediary  03/02/2004 2905 
Medical Review on Long Term Care 
Hospitals 
R040PIM 05/16/2003  Local Provider Education and Training  05/16/2003 2466 
Program 
R033PI  11/01/2002  FY 2003 Budget Performance Requirement  11/01/2002 2407 
Revisions 
R025PIM 04/25/2002  Types of claims for which Contractors are  07/01/2002 2122 
Responsible 
R024PIM 04/05/2002  Removes the LMRP and related sections from  10/01/2002 2061 
Chap 1 and moves to Chap 13 
R021PIM 02/28/2002  Inpatient Hospital Claims for Which  04/01/2002 1969 
Contractors are Responsible for Performing 
MR 
R019PIM 02/08/2002  Benefit Integrity Unit Security Requirements  02/08/2002 1907 
R017PIM 12/12/2001  Reorganizes chapter 3, sections 4, 5, and 6  04/01/2002 1891 
and Removes reference to outdated MCM and 
MIM overpayment collection instructions and 
lists the more current CFR citations instead. 
R016PIM 11/28/2001  Adds Various Program Memoranda for BI  11/28/2001 1732 
Requests for Information, Organizational 
Requirements, Unsolicited Voluntary Refund 
Checks, Anti-Kickback Statute Implications 
R014PIM 09/26/2001  Local Medical Review Policy (LMRP)  10/01/2001 1859 
Format and Submission/Requirements 
R010PIM 09/17/2001  Timeframe for Contractor Advisory  10/17/2001 1744 
Committees (CAC) Meetings 
R009PIM 07/30/2001  LMRP Process  NA  1021 
R008PIM 07/11/2001  Replaces PIM Chapter 1, Sections 2, 2.1, and  07/11/2001 1485 
sections 2.3 up through and including 2.3.4. 
R006PIM 05/24/2001  Maintaining the Confidentiality of MR  05/24/2001 1581 
Records 
R003PIM 11/22/2000  Complete Replacement of PIM Revision 1.  NA  1292 
R001PIM 06/2000  Initial Release of Manual  NA  931 
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