Auditor Requested Explanations

During the course of the Audit & Reimbursement review process, several key issues may be identified as having a higher potential risk to the Medicare program, and thus require some additional review. It should be noted that any and all information submitted to the Medicare Administrative Contractor (MAC)/Fiscal Intermediary (FI) is subject to review. In accordance with 42 CFR 413.24, CMS Publication 15-2, Section 140, CMS Publication 100-06, Chapter 8, Section 20.3, providers must maintain adequate and auditable records that may be requested by the auditing contractor/intermediary during the course of review to fully satisfy Medicare review objectives.

Information for Requested Explanations Should Contain the Following:

  • A clear and concise narrative explanation identifying the unique situation(s) within the provider's financial or operational structure that directly relates to the initial audit inquiry.
  • Sufficient supporting documentation such as detailed financial records, invoices, canceled checks, contracts or other agreements, information from external entities, etc. that can be used to collaborate the narrative explanation.

If the provider does not submit the necessary information, or insufficient information, within the given timelines of the initial information request, dependent upon the situation/issue under review, the MAC/FI may deny approval, adjust the Medicare cost report, and/or interim payments made. Audit staff may grant, on a case-by-case basis, extensions to the documented timelines due to extenuating circumstances. However, every attempt should be made on behalf of the provider to acquire the information in a timely manner.

If, during the course of analyzing the explanation/supporting documentation additional issue(s) are identified, a new information request will be submitted to the provider.

It is the responsibility of the provider to ensure that the MAC/FI has the most updated contact information available to receive any information request(s). The Audit & Reimbursement areas utilize the System Tracking for Audit & Reimbursement (STAR) for contact information. STAR is maintained for each Medicare provider and contains the appropriately certified contact information. Questions concerning updating provider contact information should be directed to our Provider Enrollment team.

Page Last Updated: Thursday, 15-Dec-2011 15:11:33 CST