Program_Memos / 2000 / B-00-54

Why This Topic Matters

It matters because it defines how contractor program integrity activity is organized and reported across multiple systems, and it shows which data elements must be exchanged for operational reporting. It is especially useful for teams that need to understand the structure of Medicare program integrity reporting and the supporting interface requirements.

Article Sections

1. Program Memorandum Overview

   Introduces the memorandum, its purpose, and the reporting system it replaces. Summarizes the general scope of the guidance and the affected contractor reporting environment.

2. Interface Design and General Data Definitions

   Describes the source systems, data transfer approach, and shared reporting concepts used throughout the system. Covers broad activity categories and general measurement definitions.

3. General Reporting Levels and Activity Type Framework

   Outlines the levels of detail used for reporting and the major activity groupings in the system. Also identifies how activity-related data are organized for reporting purposes.

4. Prepayment, Postpayment, and Other Review Categories

   Describes the major review categories and the kinds of program integrity activities included in each. Includes reporting distinctions for manual, automated, and special review activity types.

5. Claims Processing and Other Activities

   Summarizes the claims processing measures and the additional operational activities tracked in the reporting framework. Includes broad categories such as data analysis, special studies, edit development, policy development, and court-ordered review.

6. Attachment 1: Contractor/Standard System Interface

   Provides the interface structure for monthly data exchange between contractor systems and the reporting system. Includes the major data groupings for postpay review, prepay review, denial reasons, referrals, claims processing, and related interfaces.

7. Attachment 2: Carrier Provider Type and Subtype

   Presents the carrier provider type and subtype classification tables used by the reporting system. Includes the specialty and HCPCS range groupings referenced by the memorandum.