Program_Memos / 2000 / AB-00-34

Why This Topic Matters

It documents how a major Medicare program integrity reporting framework was organized, including the system-level data elements and source-system interfaces that contractors were expected to support. That makes it useful for analysts, compliance staff, and coding/reporting teams who need historical context for Medicare integrity reporting requirements and data categorization.

Article Sections

1. Program Integrity Management Reporting (PIMR) overview

   Introduces the reporting system, its purpose, effective dates, and the contractor reporting environment it was intended to support. Summarizes the broad data categories used throughout the memorandum.

2. General data definitions

   Defines the principal reporting concepts used across the system, including units, claims counting, line items, reviews, denials, and referrals. Also distinguishes reporting instructions from operational medical review guidance.

3. General reporting levels

   Explains the reporting dimensions used to summarize data and describes how contractor, time, provider, and other structural levels are organized. Includes the treatment of edit-related reporting and standardized identifiers.

4. Activity type categories

   Describes the major classes of medical review and related activities tracked in the reporting system. Covers prepayment, postpayment, claims processing, and other activity groupings.

5. Contractor/Standard System Interface

   Presents the monthly data elements expected from contractor standard systems and the database structures used for PIMR intake. Includes tables for postpayment review data, prepayment review data, denial reasons, other referrals, claims processing, and related interfaces.

6. CAFM Interface

   Describes the effort-related data elements that are transferred from CAFM and the activity structure used for reporting those values. Focuses on system interface requirements and data-level breakdowns.

7. FID Interface

   Defines the fraud case and payment suspension data required from FID, including mapping concepts and monthly reporting structure. Also includes the associated source-to-destination table framework.

8. CROWD Interface

   Outlines complaint-related data required from CROWD for program integrity reporting. Describes the relevant source records and reporting breakdowns.

9. IRP Interface

   Provides the comparable complaint-related interface requirements from IRP. Focuses on the data elements and monthly transfer structure.

10. Attachment 2 – FI Provider Type

    Lists provider type categories used in the attachment for fiscal intermediary reporting. Serves as a reference table for the broader reporting framework.

11. Attachment 3 – FI Provider Subtype

    Lists provider subtype categories and associated ranges used for intermediary reporting. Includes multiple facility and subtype groupings used for classification.

12. Attachment 4 – Carrier Provider Type and Subtype

    Provides carrier specialty and HCPCS-based provider subtype groupings. Serves as a reference for carrier-side provider classification.