Medicare Program Integrity Manual 
Chapter 11 - Fiscal Administration 
 
Table of Contents  
(Rev. 10365, 10-02-20) 
 
Transmittals for Chapter 11 
 
11.1 - Medical Review (MR) 
11.1.1 - MR Overview 
11.1.2 - Reporting MR Workload and Cost Information and Documentation in 
CAFM 
11.1.3  CAFM II Reporting for MR Activities 
11.1.3.1 - Automated Review Workload and Cost (Activity Code 21001) 
11.1.3.2 - Routine Review Workload and Cost (Activity Code 21002) 
11.1.3.3 - Data Analysis Cost (Activity Code 21007) 
11.1.3.4 - Third Party Liability or Demand Bills Workload and Cost 
(Activity Code 21010) 
11.1.3.5  Policy Reconsideration/Revision Activities (Activity Code 
21206) 
11.1.3.6  MR Program Management Costs (Activity Code 21207) 
11.1.3.7  New Policy Development Activities (Activity Code 21208) 
11.1.3.8  Complex Probe Review Workload and Costs (Activity Code 
21220) 
11.1.3.9  Prepay Complex Review Workload and Cost (Activity Code 
21221) 
11.1.3.10 - Postpay Complex Review Workload and Cost (Activity Code 
21222) 
11.1.3.11  Postpay Complex Review Workload and Cost (Activity Code 
21222) 
11.1.4 - MIP Comprehensive Error Rate Testing (CERT) Support  
11.1.4.1  MIP CERT Support (Activity Code 21901) 
11.1.5 - Reporting Internal Staff Training 
11.1.6 - Reporting MR Savings in CROWD 
11.2 - LPET Overview 
11.2.1 - Reporting LPET Workload and Cost Information and Documentation in 
CAFM II 
11.2.2.1  One-on-One Provider Education Workload and Cost (Activity 
Code 24116)  11.2.2.2  Education Delivered to a Group of Providers Workload and 
Cost (Activity Code 24117) 
11.2.2.3  Education Delivered via Electronic or Paper Media Workload 
and Cost (Activity Code 24118)  11.1 - Medical Review (MR) 
(Rev. 174, Issued:  11-17-06; Effective: 10-01-2006; Implementation:  10-02-06) 
 
Contractors are required to incorporate Activity Based Costing (ABC) in the budget 
process. ABC is a management reporting system that allows contractors to focus on the 
costs of the work activities instead of the standard cost centers associated with the 
traditional cost accounting structure. ABC identifies an all inclusive business process for 
each activity so that the total costs of the activity are fully visible to the MR business 
manager. Refer to Medicare Financial Management Manual, 
www.cms.gov/manuals/106_financial/fin106index.asp chapters 1, 2, 5, and 6 for more 
detailed explanation of ABC. 
 
11.1.1  MR Overview 
(Rev. 174, Issued:  11-17-06; Effective: 10-01-2006; Implementation:  10-02-06) 
 
This chapter of the PIM lists the requirements contractors must follow when allocating 
MR Costs, Savings and Workload to the MR activities in CAFM and CROWD. These 
requirements formerly appeared in MCM, Part 1, 4213; MIM, Part 1, 1213 and the MR 
Budget and Performance Requirements (BPRs). Contractors must allocate to the MR 
activity code in CAFM II only the workload and costs associated with MR tasks. 
Contractors must allocate to the MR line in CROWD only these savings that are 
generated by MR tasks. For example: 
 
  If a nurse reviewer spends 90% of her time performing prepay complex medical 
review and 10% of her time performing appeals review at the request of the appeals unit, 
the contractor must allocate 90% of this nurse's salary/fringes to 21221 and the 10% to 
the appropriate appeals activity code. 
 
  If a non-clinician medical reviewer spends 80% of his time performing Routine 
review and 20% of his time performing suspect duplicate reviews, the contractor must 
allocate 80% of this reviewer's salary/fringes to 21002 and the 20% to the appropriate 
claims processing activity code. 
 
  If a nurse reviewer spends 70% of her time performing postpay complex review 
for the purpose of making a coverage determination on a provider who has been selected 
for targeted PCA review and 30% of her time performing reviews to support the claims 
processing unit, the contractor should report 70% to Postpay Complex Review 21222 and 
30% to the appropriate claims processing activity code. 
 
Refer to chapter 1, section 2 www.cms.gov/manuals/108_pim/pim83c01.asp#Sect2 of 
this manual for detailed overview of the MR Program. This chapter lists the requirements 
contractors must follow when allocating MR costs and workload to the MR activities in 
CAFM II. Contractors will be given a specified maximum budget for MR. Based on this 
budget the contractor is asked to develop a unique MR strategy within their jurisdiction 
that is consistent with the goal of reducing the error rate.  The contractor shall utilize their  targeted budget in its entirety on MR activities toward the prevention of waste and abuse 
to the Medicare program. 
 
11.1.2 Reporting MR Workload and Cost Information and 
Documentation in CAFM II 
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
Workload information and associated workload cost information shall be maintained and 
documented on-site by all MR contractors. Each site shall maintain records of its own 
workload information and associated workload cost information. Contractors shall be 
able to provide this information upon request from RO and/or CO.  Site-specific 
workload and cost information shall be reported in the remarks section of CAFM II. With 
RO consent, this information may be submitted by other means with an indication made 
in the remarks section of the CAFM II IER report. 
 
The MR strategy shall include a section that describes the process used to monitor 
spending in each activity code. The process shall ensure that spending is consistent with 
the allocated budget and includes a process to revise the plan when spending is over or 
under the budget allocation. In addition, the strategy shall describe how workload for 
each activity code is accurately and consistently reported. The workload reporting 
process shall also assure proper allocation of employee hours required for each activity. 
 
Contractors MR workload records shall include workload information captured by the 
Interim Expenditure Report (IER). Only costs (direct, indirect, overhead) incurred to 
support MR activities are reported on the MR line. Contractors are responsible for 
ensuring the accuracy of the information contained in CAFM II. The contractor shall alert 
the RO (for UPICs, the GTL, Associate GTL, and SME) to any software or hardware 
problems that hinder the contractors ability to report accurate data in CAFM II. The 
contractor should cc MROperations@CMS.HHS.gov. 
 
11.1.3  CAFM II Reporting for MR Activities 
(Rev. 174, Issued:  11-17-06; Effective: 10-01-2006; Implementation:  10-02-06) 
 
Contractors shall report all costs associated with the medical review of claims, e.g., 
sampling design and execution; claims examination, reviewing medical records and 
associated documentation; assessing overpayments; and contacting providers to notify 
them of overpayment assessment decisions. All costs associated with collecting the 
overpayment shall be allocated to the appropriate overpayment collection CAFM II 
activity code. 
 
To be counted as medical review workload, all claims reviewed by medical review shall 
be identified in the MR strategy and be the result of a MR edit. If resources allow, a MR 
clinician may be shared with another functional area, such as provider outreach and 
education, claims processing or appeals, as long as only the percentage of the clinicians 
time spent on MR activities is identified in the strategy and accounted for in the 
appropriate functional budget area.  The review of a claim for MR purposes is only counted as medically reviewed once no 
matter how many times the same claim is reviewed during claims processing. MCS users 
will be exempt from this requirement until July 5, 2005. Effective July 5, 2005 the MCS 
system shall be revised to automatically deny duplicates of denied lines.  Duplicates of 
denied lines are defined as newly submitted lines that duplicate a line that a contractor 
has (a) already denied, (b) medically reviewed, or (c) for which the contractor requested 
but did not received documentation.  Denial of duplicate lines shall not be appealable 
unless the provider documents that the service was not a duplicate because it was 
performed more often than indicated in the original line.  Use a Duplicate non-paid 
denial message whenever this denial is made. 
 
11.1.3.1 - Automated Review Workload and Cost (Activity Code 21001) 
(Rev. 89, Issued: 11-26-04, Effective: 12-27-04, Implementation: 12-27-04) 
 
Contractors shall report the costs associated with automated review including personnel 
to install and activate supplemental edit software in Activity Code 21001. In the 
workload section of the CAFM II, Activity Code 21001, contractors shall report the 
number of claims denied in whole or in part in Workload 1. To the extent the contractor 
can report claims subjected to automated medical review, this number should be reported 
in Workload 2. (IOM Pub 100-08, ch.3, 3.4.5.) 
 
11.1.3.2 - Routine Review Workload and Cost (Activity Code 21002) 
(Rev. 130, Issued: 11-10-05, Effective: 10-01-05, Implementation: 12-12-05) 
 
Contractors shall report all costs associated with routine reviews in Activity Code 21002. 
Costs associated with collecting an overpayment shall not be reported to this activity 
code. In the workload section of CAFMII, Activity Code 21002, report the number of 
claims reviewed in Workload 1. Contractors shall report number of claims denied in 
whole or in part in Workload 2.  Include those post payment claims where no 
documentation was received in workload 2.  Report the number of providers subject to 
routine review in Workload 3.  (IOM Pub 100-08, ch.3 3.4.5.) 
 
11.1.3.3 - Data Analysis Cost (Activity Code 21007) 
(Rev. 174, Issued:  11-17-06; Effective: 10-01-2006; Implementation:  10-02-06) 
 
Contractors shall report costs associated with data analysis activities associated with 
discovering program vulnerabilities and developing a MR prioritized problem list (IOM 
Pub 100-8, ch. 1) in CAFM II Activity Code 21007. However, analysis of the data to 
develop and deliver educational interventions shall not be reported in an MR activity 
code. In addition, data analysis associated with benefit integrity and law enforcement 
support shall not be reported here.  There is no claims workload to be reported for this 
activity. 
 
  11.1.3.4 - Third Party Liability or Demand Bills Workload and Cost 
(Activity Code 21010) 
(Rev. 185, Issued: 01-26-07, Effective: 02-26-07, Implementation: 02-26-07) 
 
Intermediaries shall report only the workload and costs associated with the medical 
review of third party liability claims and the workload and costs associated with the 
medical review of demand bills. Funding for claims processing and the appeals for third 
party liability and demand bills must be funded through program management. 
 
Intermediaries shall report the costs associated with the medical review of third party 
liability claims and the medical review of demand bills in Activity Code 21010. 
Intermediaries shall report the total number of claims reviewed, i.e., third party liability 
claims plus claims for demand bills, in Workload 1 in CAFM II Activity Code 21010. 
Intermediaries shall report the number of claims denied in whole or in part in Workload 
2. Intermediaries shall report demand bills (claims) reviewed in Workload 3. 
 
An exception to the preceding instruction may occur when the provider submits a home 
health demand bill (condition code 20) type 32X, 33X, or 34X, and the beneficiary has 
not selected the checkbox indicating that he or she wants Medicare to be billed on the 
Home Health Advance Beneficiary Notice (HHABN).  In most cases, the contractor shall 
return to the provider (RTP) such claims submitted in error, except in the case of dual-
eligible beneficiaries where there is a state-specific policy regarding billing Medicare.  
Contractors and HHAs who serve dual-eligibles shall comply with a state-specific policy 
on billing for dual-eligible beneficiaries (see CMS Pub. IOM 100-04, chapter 60, 60.5 
A. for further instruction on that situation). 
 
11.1.3.5 - Policy Reconsideration/Revision Activities (Activity Code 
21206) 
(Rev. 130, Issued: 11-10-05, Effective: 10-01-05, Implementation: 12-12-05) 
 
In an attempt to achieve jurisdictional consistency, multi-state contractors shall develop 
and revise local policies that apply to all their states. When reporting workload to CAFM 
II, the contractor shall report just one LCD, even if that policy varies slightly from state 
to state. 
 
Report all costs associated with reconsiderations and revisions to LCD in CAFM II 
Activity Code 21206. Include reconsideration requests made as a result of IOM Pub.100-
08 ch.13 13.10. The cost of inputting the LCD into the Fu database shall also be 
reported here and not in activity code 24118  Education delivered through electronic or 
paper media. Report the total number of policies revised or retired in the month it became 
effective in Workload 1. Report the number of policies revised that required notice or 
comment as Workload 2. Report the number of policies revised due to an outside request 
(e.g., beneficiary or provider request) in Workload 3. 
 
  11.1.3.6  MR Program Management Costs (Activity Code 21207) 
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
The MR Program Management encompasses managerial responsibilities inherent in 
managing the MR program, including: development, modification, and periodic reporting 
of MR strategy and quality assurance activities; planning monitoring and adjusting 
workload performance; budget-related monitoring and reporting; and implementation of 
CMS instructions. 
 
Activity Code 21207 is designed to capture the costs of managerial oversight for the 
following tasks: 
 
  Develop and periodically modify MR strategy; 
 
  Develop and modify quality assurance activities, including special studies, 
inter- reviewer reliability testing, committee meetings, and periodic reports; 
 
  Evaluate edit effectiveness; 
 
  Plan, monitor and oversee budget, including interactions with contractor 
budget staff and RO budget and MR program staff; 
 
  Manage workload, including monitoring of monthly workload 
reports, reallocation of staff resources, and shifts in workload focus 
when indicated; 
 
  Implement MR instructions from regional and/or central office; 
 
  Educate staff on MR program, new CMS instructions, and quality assurance 
findings (this is different from the internal training of MR staff to perform MR 
activities); and, 
 
  Support service for UPIC performing MR activities other than for the 
CERT contractor. 
 
11.1.3.7 - New Policy Development Activities (Activity Code 21208) 
(Rev. 130, Issued: 11-10-05, Effective: 10-01-05, Implementation: 12-12-05) 
 
In an attempt to achieve jurisdictional consistency, multi-state contractors shall develop 
and revise local policies that apply to all their states. When reporting workload to CAFM 
II, the contractor shall report just one LCD, even if that policy varies slightly from state 
to state. 
 
Report all costs associated with new LCD development activity in CAFM II Activity 
Code 21208. Include in this cost inputting the LCD into the Fu database, do not report 
this cost in activity code 24118  Education delivered through paper or electronic media.  Report the number of new policies that were presented for comment as Workload 1. 
Report the number of new policies that were released for notice in the month that it 
became effective in Workload 2. Report the number of Investigational Device Exemption 
(IDE) requests reviewed in Workload 3. 
 
11.1.3.8 - Complex Probe Review Workload and Costs (Activity Code 
21220) 
(Rev. 130, Issued: 11-10-05, Effective: 10-01-05, Implementation: 12-12-05) 
 
Report all costs associated with complex probe review in Activity Code 21220. In the 
workload section of CAFM II, Activity Code 21220, report the number of claims 
reviewed in Workload 1. Report the number of claims denied in whole or in part in 
Workload 2. Report the number of providers subject to complex probe review in 
Workload 3. 
 
11.1.3.9 - Prepay Complex Review Workload and Cost (Activity Code 
21221) 
(Rev. 171; Issued:  11-09-06; Effective:  01-01-07; Implementation:  12-09-06) 
 
Report all costs associated with prepay complex review in Activity Code 21221. In the 
workload section of CAFM II, Activity Code 21221, report the number of claims 
reviewed in Workload 1. Report the number of claims denied in whole or in part in 
Workload 2. Report the number of providers subject to prepay complex review in 
Workload 3. 
 
The DMERCs shall report the number of Advanced Determinations of Medicare 
Coverage accepted (CMS IOM Pub.100-8, chapter.5, section 5.7) to miscellaneous code 
21221/01. 
 
The carriers and fiscal intermediaries shall report the therapy cap workload in activity 
code 27021. 
 
11.1.3.10 - Postpay Complex Review Workload and Cost (Activity Code 
21222) 
(Rev. 89, Issued: 11-26-04, Effective: 12-27-04, Implementation: 12-27-04) 
 
Contractors shall report all costs associated with Postpay Complex Review in Activity 
Code 21222.  In the workload section of Activity Code 21222, contractors shall report the 
total number of claims reviewed on a postpayment basis as Workload 1 and report the 
total number of claims denied in whole or in part as Workload 2.  Report the number of 
providers subject to postpay complex review in Workload 3. (IOM Pub 100-08, ch. 3. 
4.5.) 
 
11.1.3.11  Postpay Complex Review Workload and Cost (Activity Code 
21222)  (Rev.) 
11.1.4 - MIP Comprehensive Error Rate Testing (CERT) Support 
(Rev. 174, Issued:  11-17-06; Effective: 10-01-2006; Implementation:  10-02-06) 
 
Beginning in FY 2005, CMS will provide funding earmarked for the AC to support the 
CERT contractor.  This funding will be a reverse auction funding system as is found in 
the MR program.  The CERT Support funding is over-and-above the level of funding 
provided to perform the MR activities listed above.  Contractors are not required to 
develop a MIP CERT Support strategy.  Contractors shall not include MIP CERT 
Support work in their MR strategies. Contractors shall not shift additional funds from MR 
activities to this line. 
 
In addition to satisfying all requirements contained here, contractors shall carry out all 
CERT Support activities identified in IOM Pub.100-8, chapter 12, and all relevant MIP 
CERT Support One Time Notifications. 
 
11.1.4.1 - MIP CERT Support (Activity Code 21901) 
(Rev. 220, Issued: 08-24-07, Effective: 09-03-07, Implementation: 09-03-07) 
 
Report the costs associated with time spent on MIP CERT Support Activities.  These 
activities include but are not limited to the following: 
 
  Providing review information to the CERT contractor as described in IOM Pub. 
o
100-08, ch.12  3.3.2. 
 
  Providing feedback information to the CERT contractor as described in IOM Pub. 
o
100-08, ch.12,  3.3.3 including but not limited to: 
 
+  CMD discussions about CERT findings; 
 
+  Participation in biweekly CERT conference calls; 
 
+  Responding to inquiries from the CERT contractor; and 
 
+  Preparing dispute cases. 
 
  Preparing the Error Rate Reduction Plan (ERRP) as described in IOM Pub..100-
o
08, ch. 12, 3.9 (Do not include costs of developing MR Strategy or the Quarterly 
Strategy Analysis (QSA).  The cost of developing the MR Strategy and QSA shall be 
captured in MR CAFM code 21207). 
 
  Educating the provider community about CERT as described in IOM Pub. 100-
o
08, ch.12,  3.8. 
 
  Contacting non-responders and referring recalcitrant non-responders to the OIG 
o
as described in IOM Pub. 100-08, ch.12,  3.10.   
Contractors shall NOT report costs associated with the following activities in this activity 
code: 
  Providing sample information to the CERT Contractor as described 
in IOM Pub. 100-08, ch. 12, 3.3.1A&B (these costs should be allocated to the PM 
CERT Support Code  12901 -- described in the Appeals BPR); 
 
  Ensuring that the correct provider address is supplied to the CERT 
Contractor as described in IOM Pub. 100-08, ch. 12, 3.3.1.C (these costs should be 
allocated to the PM CERT Support Code  12901 -- described in the Appeals BPR); 
 
Researching no resolution cases as described in IOM Pub. 100-08, ch. 12, 3.3.1.B 
(these costs should be allocated to the PM CERT Support Code  12901 -- described in 
the Appeals BPR). 
 
11.1.5  Reporting Internal Staff Training 
(Rev. 89, Issued: 11-26-04, Effective: 12-27-04, Implementation: 12-27-04) 
 
For all internal staff training, charge the portion of the salaries for individuals attending 
the training to the activity(s) that the individual performs. 
 
For training related to a particular MR activity(s) allocate the cost for the training and any 
associated travel cost to the activity(s) that the training benefits in other direct costs. 
 
For training that benefits the overall MR program  if an individual attends the training - 
charge the costs of the training and any associated travel costs to the activity(s) that the 
individual performs in other direct costs.  If a group attends the training, distribute the 
costs of the training and any associated travel costs among all MR activity codes in other 
direct costs. 
 
For training that is required by CMS or benefits the Medicare program, allocate training 
and travel costs to overhead. 
 
11.1.6 - Reporting MR Savings in CROWD 
(Rev. 89, Issued: 11-26-04, Effective: 12-27-04, Implementation: 12-27-04) 
 
Contractors shall report in CROWD only those actual savings that are generated from 
MR claims review. 
 
Include as MR savings the following: 
 
  Actual savings that result from all coverage and coding reviews done for MR 
purposes. Include all benefit category, statutory exclusion and, reasonable and necessary 
reviews done for MR purposes. 
 
Contractors shall not include as MR savings:   
  Avoided costs (e.g. a reduction in the number of claims submitted, compared to 
historical patterns, attributed to a new or revised LCD) shall not be considered "savings." 
 
  Savings that result from coverage or coding reviews performed at the request of 
the fraud unit. 
 
  Savings that result from any review other than coverage or coding. 
 
11.2 - LPET Overview 
(Rev. 89, Issued: 11-26-04, Effective: 12-27-04, Implementation: 12-27-04) 
 
Contractors shall consider various elements when planning their LPET budget.  For 
example, contractors shall explain how they plan to allocate provider educational 
activities between LPET and PCOM.  The LPET subjects include medical review 
findings, and education on LCDs as identified through the PCA process. PCOM subjects 
include issues of national scope or impact.  While there are fundamental differences 
between the LPET and PCOM programs, there may be circumstances when it would be 
feasible to provide educational events that encompass the scope of both of these 
programs.  For any function such as seminars, conventions, or conferences that address 
LPET as well as PCOM subjects, the proportional share of the cost of that function to be 
allocated to LPET, is equal to the percentage of time related to addressing LPET subject 
matter, multiplied by the cost of the function.  For example, the proportional share of the 
cost of a seminar to be allocated to LPET, is equal to the percentage of the seminar 
related to addressing LPET subjects, multiplied by the cost of the seminar (e.g., if it costs 
$4,000 to arrange and conduct a seminar containing 75 percent MR and 25 percent 
national coverage information, then the LPET cost would be $4,000 multiplied by 0.75 or 
$3,000 and the remaining $1,000 would be charged to PCOM).  However, if the intent of 
the educational intervention is purely LPET, but PCOM issues arise; address the issues to 
the extent possible, but charge the cost of the intervention to LPET. This methodology for 
allocating costs also applies to other general, all-purpose provider education tools or 
materials, such as regularly scheduled bulletins/newsletters.  The costs for developing, 
producing, and distributing bulletins, should be allocated proportionally according to the 
percentage of the time spent on each subject in the bulletin between LPET and PCOM. 
 
Each contractor will be given a specified maximum budget for LPET activities.  
Contractors shall identify the appropriate budget and workload for each activity code 
within the constraints of their budgets.  Contractors are not permitted to charge 
providers/suppliers for planned educational activities and training materials.  However, 
contractors may assess fees of no more than the cost for educational activities delivered at 
a non-Medicare contractor sponsored event, or when specifically requested by specialty 
societies or associations.  In addition, although contractors are mandated to supply 
providers with a paper copy of their bulletin at no cost, contractors may assess a fee to 
cover costs if the provider requests additional copies.  All monies collected must be 
reported as a credit in the applicable activity code and accompanied with a rationale for 
charging the fee.  The fees must be fair and reasonable.  Revenues collected from  discretionary activities must be used only to cover the cost of these activities and may not 
be used to supplement other contractor activities. 
 
11.2.1 - Reporting LPET Workload and Cost Information and 
Documentation in CAFM II 
(Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) 
 
Workload information and associated workload cost information shall be maintained and 
documented on site by all contractors. Each site shall maintain records of its own 
workload information and associated workload cost information. Contractors shall be 
able to provide this information upon request from RO and/or CO. Site-specific workload 
and cost information should be reported in the remarks section of CAFM II. With RO 
consent, this information may be submitted by other means with an indication made in 
the remarks section of the CAFM II IER report. 
 
The contractors' LPET workload records shall include workload information captured by 
the Interim Expenditure Report (IER). Only costs (direct, indirect, overhead) incurred in 
LPET activities are reported in CAFM II activity codes. Analysis of the data to develop 
and deliver LPET interventions shall be reported in an associated LPET activity code. 
Contractors are responsible for ensuring the accuracy of the information contained in 
CAFM II. The contractor shall alert the RO (for UPICs, the GTL, Co-GTL, and 
SME) to any software or hardware problems that hinder the contractor's ability to 
report accurate data on CAFM II. 
 
Since LPET is related to medical review activities, Joint Operating Agreements between 
Unified Program Integrity Contractors (UPIC) and Affiliated Contractors (AC) should 
reflect proportionate allocation of tasks delineated to MR and LPET. When negotiating 
Joint Operating Agreements, the UPICs should be cognizant of their task order. 
 
11.2.2.1  One-on-One Provider Education Workload and Cost (Activity 
Code 24116) 
(Rev. 89, Issued: 11-26-04, Effective: 12-27-04, Implementation: 12-27-04) 
 
Report the costs associated with One-on-One Provider Education in Activity Code 24116.  
Written materials, or electronic communications to providers during a One-on-One 
Provider Education, shall not be reported in Education Delivered via Electronic or Paper 
Media, Activity Code 24118, but included in the cost for One-on-One education. Activity 
Code 24116 - One-on-One Provider Education shall capture the one-on-one contact 
between the contractor and provider, and the written materials or electronic 
communication used to facilitate the one-on-one education.  Included in this activity code 
would be letters sent to a provider that specifically addresses the medical review findings 
and instructions to correct the errors.  Any provider contact made solely by paper or 
computer, without specifically addressing an individual provider, should not be reported 
here. (IOM Pub. 100-08, chapter 1.) 
  For One-on-One Provider Education, Activity Code 24116, report the number of 
educational contacts in Workload 1. Report the number of providers educated in 
Workload 2.  If a provider sends a representative(s) on his behalf to a one-on-one 
educational contact, count the number of provider(s), not representative(s), to whom the 
educational activity was directed. 
 
11.2.2.2  Education Delivered to a Group of Providers Workload and 
Cost (Activity Code 24117) 
(Rev. 130, Issued: 11-10-05, Effective: 10-01-05, Implementation: 12-12-05) 
 
Report the costs associated with Education Delivered to a Group of Providers in Activity 
Code 24117.  Report the number of group educational activities in Workload 1.  Report 
the number of providers educated in Workload 2.  If a provider sends a representative(s) 
on his behalf to a group education activity, count the number of provider(s), not 
representative(s), to whom the educational activity was directed. (IOM Pub. 100-08, 
ch.1.) 
 
11.2.2.3  Education Delivered via Electronic or Paper Media Workload 
and Cost (Activity Code 24118) 
(Rev. 89, Issued: 11-26-04, Effective: 12-27-04, Implementation: 12-27-04) 
 
Report the costs associated with Education Delivered via Electronic or Paper Media in 
Activity Code 24118.  Report the total number of educational documents developed for 
use in non-interactive educational interventions in Workload 1.  Report the number of 
CBRs developed in Workload 2 (do not include CBRs developed for Activities in 24116 
and 24117).  Report the number of articles/advisories/bulletins developed in Workload 
3.Workloads 2 and 3 are subsets to workload 1. If an educational bulletin is published in 
a number of different venues, count that bulletin only once, even if publication occurs in 
different months.  Transmittals Issued for this Chapter 
 
Rev #  Issue Date  Subject  Impl Date  CR# 
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 
Replaced by Transmittal 10365 
R220PI  08/24/2007  Various Medical Review Clarifications  09/03/2007 5550 
R185PI  01/26/2007  Updating Financial Reporting Requirements  02/26/2007 4378 
for Workload and Cost Associated With the 
Return of Demand Bills 
R174PI  11/17/2006  Transition of Medical Review Educational  10/06/2006 5275 
Activities 
R171PI  11/09/2006  Outpatient Therapy Cap Clarifications  12/09/2006 5271 
R170PI  11/03/2006  Transition of Medical Review Educational  10/06/2006 5275 
Activities - Replaced by Transmittal 174 
R163PI  09/29/2006  Transition of Medical Review Educational  10/06/2006 5275 
Activities - Replaced by Transmittal 170 
R146PI  04/28/2006  Provider Enrollment Update  05/30/2006 4340 
R140PI  02/15/2006  Therapy Caps Exception Process  03/13/2006 4364 
R139PI  02/13/2006  Therapy Caps Exception Process - Replaced  03/13/2006 4364 
by Transmittal 140 
R130PI  11/10/2005  Correction/Clarification of Several Sections  12/12/2005 4020 
R104PI  02/11/2005  Requirement that Medicare Carrier System  07/05/2005 3622 
(MCS) Not Allow the Re-review of 
Previously Denied Claims 
R089PI  11/26/2004  Updating Financial Reporting Requirements  12/27/2004 3446 
for Medical Review and Local Provider 
Education and Training 
R071PI  04/09/2004  Rewrite of Program Integrity Manual (except  05/10/2004 3030 
Chapter 10) to Apply to PSCs 
R36PI  12/27/2002  New sections added to Chapter  12/27/2002 2419 
R033PI  11/01/2002  Fiscal Administration  11/01/2002 2407 
R022PIM 05/05/2002  Clarification & Manualization of Chapter  04/01/2002 1962 
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