100-15 Medicaid Program Integrity Manual: Chapter 5 – Unified Case Management System

Medicaid Program Integrity Manual
Chapter 5 - Unified Case Management
System
Table of Contents
(Rev. 13945; Issued: 09-03-26)
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 UPIC’s 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.13945; Issued: 09-03-26; Effective: 10-05-26; Implementation: 10-05-26)
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
“Activity Log” 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.13945; Issued: 09-03-26; Effective: 10-05-26; Implementation: 10-05-26)
The UPIC shall spawn an OPT record in the UCM when there is an identified
overpayment.

For investigations/audits of managed care network providers, where the provider is
enrolled in multiple managed care organizations (MCOs), one OPT record will be
opened. The UPIC will break down the overpayments of each MCO payor within the
UCM “Overpayment Financials” section and in the FFR with a separate
appendix/attachment for each payor.
In circumstances where the provider is being investigated/audited for both fee-for-service
(FFS) claims and is enrolled in managed care, one OPT record will be opened. The UPIC
will break down the overpayments for the FFS portion and the MCO within the UCM
“Overpayment Financials” section and in the FFR with a separate appendix/attachment
for each.
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 revised—either due to the state’s review or the provider’s review—the
UPIC shall update the financial section of the OPT record with the revised amounts in the
‘Original Overpayment Amount’ column and include the date of the revision in the
‘Determination Date’ column. The ‘Original Overpayment Amount’ column should
reflect the overpayment amount identified in the FFR submitted to CMS.
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 overpayment amount
identified in the FFR. If the FFR is revised after it has been issued to the SMA, and the
overpayment changes, the ‘Revised Overpayment Amount’ will be revised to reflect the
new overpayment amount, and the federal share will be recalculated, and the amount will
be entered in the ‘Revised Federal Share’ column.
For a Revised FFR (RFFR), that has occurred after the FFR is issued to the SMA, the
UPIC will update the financial amount by editing the original OPT record. The UPIC
shall create a folder in the UCM and upload all RFFR documents and notify the BFL of
the RFFR via email.
5.4 – Mandatory Fields in UCM for Medicaid
(Rev.13945; Issued: 09-03-26; Effective: 10-05-26; Implementation: 10-05-26)
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) 	Activity Log 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) 	State 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#
R13945MPI 	09/03/2026 Updates to Chapter 3, Chapter 4, and
Chapter 5 in Publication (Pub.) 100-
15, Including Updates to the Vetting
Process and the Creating
Overpayment Records Process
10/05/2026 	14548
R13494MPI 	12/23/2025 Updates of Chapters 1-5 in
Publication (Pub.) 100-15, Including
Updates to the Guidance
Terminology, Existing Definitions,
and Details to Standing Guidance
01/26/2026 	14275
R12467MPI 	01/18/2024 	Updates of Chapter 1, Chapter 3, and
Chapter 5 in Publication (Pub.) 100-
15, Including Updates to the
Definitions and Additional
Clarification to the Proactive Project
Development and Creation of
Overpayment Records Guidance
02/19/2024 	13403
R11948MP 	04/13/2023 	Updates of Publication (Pub.) 100-15,
Including Revisions to Chapters 1
and 2, and the Addition of Chapters
3, 4, 5, and Appendices
05/15/2023 	13141
Back to top of Chapter