Medicaid Program Integrity Manual 
Chapter 5 - Unified Case Management System 
 
Table of Contents 
(Rev. 11948; Issued:04-13-23) 
 
 
Transmittals for Chapter 5 
 
5.0  Purpose 
5.1  Background 
5.2  Entry Requirements for Investigations 
5.3  Creating Overpayment (OPT) Records 
5.4  Mandatory Fields in UCM for Medicaid 
    5.0 - Purpose 
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
For this Chapter, the Medicaid PIM defers to the UPIC Task Order Statement of Work, 
supplemental guidance provided by CMS, and the Medicare PIM at section 4.12 for most 
information on the use of UCM by the UPICs.   
 
However, in some instances, there is specific guidance unique to the Medicaid 
environment and working with state Medicaid agencies (SMAs) that is being maintained 
in this manual at this time.  Below are sections that include guidance that is unique to 
Medicaid investigations/audits.  The associated section in the Medicare PIM is also cited, 
when applicable. 
 
5.1 - Background 
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
The UCM is a nationwide database that UPICs use to enter and update Medicare and 
Medicaid fraud, waste, and abuse leads, investigations, administrative actions, and 
referrals initiated by the UPICs. 
 
The UCM shall also capture the UPICs work related to administrative actions like post-
payment reviews, pre-payment reviews, overpayments, etc., as well as referrals to other 
entities (SMAs, law enforcement, etc.). The UCM also has monitoring and reporting 
capabilities which facilitate oversight of the UPICs workloads. 
 
5.2 - Entry Requirements for Investigations 
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
For most of this information, please defer to section 4.12.2 of the Medicare PIM titled, 
Initial Entry and Update Requirements for UPIC Leads and Investigations.   
 
Guidance unique to Medicaid: 
 
Investigative activities, such as on-site visits, interviews, etc. shall be captured in the 
Plan of Action section of UCM. 
 
The UPIC shall take all appropriate administrative actions in accordance with this 
manual and in conjunction with the SMA.  
 
5.3 - Creating Overpayment (OPT) Records  
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
Upon identification of an overpayment based on a Medicaid investigation/audit, the 
UPIC shall spawn an overpayment (OPT) record in UCM from the CSE associated with 
the investigation/audit.  The UPIC shall refer to the UCM User Manual for opening OPT 
records.   
For investigations/audits of managed care network providers, where the provider is 
enrolled in multiple managed care organizations (MCOs), an OPT record will be opened 
for each MCO where the provider is enrolled, unless directed otherwise by the SMA. 
 
In circumstances where the provider is being investigated/audited for both fee-for-service 
(FFS) claims and is enrolled in managed care, a separate OPT record will be opened for 
the FFS portion of the investigation/audit, along with the OPTs for each MCO, unless 
directed otherwise by the SMA. 
 
For the Overpayment Financials section of the OPT record, the Original 
Overpayment Amount will be the amount in the IFR that goes to the SMA and may 
include any revisions in the overpayment amount based on the CMS review.  Whenever 
the overpayment is revisedeither due to the states review or the providers reviewthe 
UPIC shall update the financial section of the OPT record with the revised amounts in 
the Revised Overpayment Amount column and include the date of the revision in the 
Determination Date column. 
 
For the Federal Share Amount of the Overpayment Financials section, the federal 
share will only be calculated for the FFR and will be entered prior to submitting the FFR 
to CMS.  The amount will be the calculated federal share of the final revised amount (if 
revised) from the IFR that is listed in the FFR.  If the FFR is later revised and the 
overpayment changes, the Revised Overpayment Amount will be revised using the 
procedures above, and the federal share will be recalculated, and the amount will be 
entered in the Revised Federal Share column. 
 
For an FFR Addendum that has occurred after the FFR is issued to the SMA, the UPIC 
will update the financial amount by editing the original OPT record. 
 
5.4 - Mandatory Fields in UCM for Medicaid  
(Rev. 11948; Issued:04-13-23, Effective: 05-15-23; Implementation: 05-15-23) 
 
There are some fields in UCM which are mandatory for investigations/audits that have a 
Program Type of Medicaid.  Currently, these include the fields listed below, 
although this list may change as needs arise.  Please refer to the UCM User Manual and 
Release Notes for all changes and updates. 
 
Mandatory Fields for the Case (CSE) Record: 
 
1)  Fraud Case Summary Section 
a)  Case Close Reason (if closed as a lead) 
b)  Medicaid/Medi-Medi Case Close Reasons (when closed as an investigation) 
 
2)  Plan of Actions Section 
a)  Any activities planned for the investigation shall be captured here.  This may 
or may not include interviews with beneficiaries, providers, employees, etc.;  on-site reviews; medical reviews, etc. 
 
3)  General Tab 
a)  Program Type 
b)  Data Source of Lead 
c)  Stage Agency 
 
4)  Allegations Tab 
a)  Provider Type (formerly Service Type) 
b)  Medicaid Dollars at Risk: 
i.  FFS 
ii.  MCO 
 
5)  State Involvement Tab 
a)  Date Lead Vetted with State 
b)  State Response Date 
c)  State Response Status 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Transmittals Issued for this Chapter   
Rev #  Issue Date  Subject  Impl Date  CR# 
R11948MP  04/13/2023  Updates of Publication (Pub.) 100-15,  05/15/2023  13141 
Including Revisions to Chapters 1 and 
2, and the Addition of Chapters 3, 4, 
5, and Appendices 
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