AHFI EXAM 168 2026 HEALTHCARE FRAUD
DETECTION PRACTICE SET ANSWERS FULL
SOLUTION
◉ Medicare Fee For Service Recovery Audit Program.
Answer: Legislative mandated program (Tax Relief and Health Care
act of 2006)
Utilizes Recovery Auditors to identify improper payments paid by
Medicare to fee-for-service providers.
Recovery Auditors identify improper payments
MACs adjust the claims, recoup identified overpayment and return
underpayment.s.
◉ MACs targeted provider-specific prepayment review.
Answer: The MACs shall initiate a targeted provider-specific
prepayment review only when there is the likelihood of sustained or
high level of payment error.
MACs are encouraged to initiate service-s[ecific prepayment review
to prevent improper payments for services identified by C ERT or
,Recovery Auditors as problem areas, as well as, problem areas
identified by their own data analysis
◉ Cert Contractors and reviews.
Answer: Because the Cert Contractors select claims on a random
basis, they are not required to notify providers of their intention to
begin a review.
◉ Prepayment Review Time Frames:.
Answer: When requesting documentation for prepayment reviews,
the Mac and ZPIC shall notify providers that the requested
documentation is to be submitted within 45-calendar days of the
request.
The reviewer shall Not grant extensions to providers who need more
time to comply with the request.
Reviewers shall deny claims for which the requested documentation
was not received by day 46.
◉ Postpayment Review Time Frames.
Answer: When requesting documentation for postpayment review,
the Mac, Cert, and RAC shall notify providers that the requested
documents are to be submitted with 45-calendar days of the
request.
,ZPIC shall notify providers that requested documents are to be
submitted with in 30-calendar days of the request.
◉ Additional Documentation Requests.
Answer: If information is requested from both the billing provider or
supplier and a third party and no response is received from either
within
45-calendar days for MACs and RACs
Or 30-days for ZPICs/UPICs
After the date of the request (or within a reasonable time following
an extension), the MACs, RACs and ZPICs/UPICs shall deny the claim
in full or in part as not reasonable and necessary.
◉ No response for request of prepayment.
Answer: During prepayment review, if no response is received
within 45-calendar days after the date of the ADR (request for
Additional Documentation Requests), the MACs and Zpics/UPICs
shall deny the claim.
◉ No response for MACs and Cert for ADR.
, Answer: If the MACs and Cert receive the requested information
from a provider or supplier after a denial has been issued but within
a reasonable number of days
(generally 15-calendar days after the denial date),
They have the discretion to reopen the claim.
◉ The primary authority for all coverage provisions and subsequent
policies is.
Answer: The Social Security Act
◉ In general, MACs, Cert, Recovery Auditors, SMRCs and ZPICs us
the following hierarchy of documents to make medical review
decisions:.
Answer: 1) Social Security Act
2) Code of Federal Regulations
3) CMS' Rulings
4) National Coverage Determinations (NCDs)
DETECTION PRACTICE SET ANSWERS FULL
SOLUTION
◉ Medicare Fee For Service Recovery Audit Program.
Answer: Legislative mandated program (Tax Relief and Health Care
act of 2006)
Utilizes Recovery Auditors to identify improper payments paid by
Medicare to fee-for-service providers.
Recovery Auditors identify improper payments
MACs adjust the claims, recoup identified overpayment and return
underpayment.s.
◉ MACs targeted provider-specific prepayment review.
Answer: The MACs shall initiate a targeted provider-specific
prepayment review only when there is the likelihood of sustained or
high level of payment error.
MACs are encouraged to initiate service-s[ecific prepayment review
to prevent improper payments for services identified by C ERT or
,Recovery Auditors as problem areas, as well as, problem areas
identified by their own data analysis
◉ Cert Contractors and reviews.
Answer: Because the Cert Contractors select claims on a random
basis, they are not required to notify providers of their intention to
begin a review.
◉ Prepayment Review Time Frames:.
Answer: When requesting documentation for prepayment reviews,
the Mac and ZPIC shall notify providers that the requested
documentation is to be submitted within 45-calendar days of the
request.
The reviewer shall Not grant extensions to providers who need more
time to comply with the request.
Reviewers shall deny claims for which the requested documentation
was not received by day 46.
◉ Postpayment Review Time Frames.
Answer: When requesting documentation for postpayment review,
the Mac, Cert, and RAC shall notify providers that the requested
documents are to be submitted with 45-calendar days of the
request.
,ZPIC shall notify providers that requested documents are to be
submitted with in 30-calendar days of the request.
◉ Additional Documentation Requests.
Answer: If information is requested from both the billing provider or
supplier and a third party and no response is received from either
within
45-calendar days for MACs and RACs
Or 30-days for ZPICs/UPICs
After the date of the request (or within a reasonable time following
an extension), the MACs, RACs and ZPICs/UPICs shall deny the claim
in full or in part as not reasonable and necessary.
◉ No response for request of prepayment.
Answer: During prepayment review, if no response is received
within 45-calendar days after the date of the ADR (request for
Additional Documentation Requests), the MACs and Zpics/UPICs
shall deny the claim.
◉ No response for MACs and Cert for ADR.
, Answer: If the MACs and Cert receive the requested information
from a provider or supplier after a denial has been issued but within
a reasonable number of days
(generally 15-calendar days after the denial date),
They have the discretion to reopen the claim.
◉ The primary authority for all coverage provisions and subsequent
policies is.
Answer: The Social Security Act
◉ In general, MACs, Cert, Recovery Auditors, SMRCs and ZPICs us
the following hierarchy of documents to make medical review
decisions:.
Answer: 1) Social Security Act
2) Code of Federal Regulations
3) CMS' Rulings
4) National Coverage Determinations (NCDs)
