A Medicare audit response program is a written, tracked process for answering the contractors that review Medicare fee-for-service claims: Recovery Audit Contractors (RACs), Unified Program Integrity Contractors (UPICs) and the Medicare Administrative Contractors (MACs) that run Targeted Probe and Educate (TPE) reviews. Integral Healthcare Solutions (IHS) builds that program for providers whose review letters arrive without one owner, one log or one calendar.
IHS drafts the intake log, the deadline calendar and the record-assembly checklist. Your team supplies the letters, the medical records and the clinical review, and your counsel handles appeals. IHS is a consulting firm, not a law firm.
Last updated: November 2026
What are RAC, UPIC and TPE reviews?
They are three separate Medicare review programs, each with its own kind of letter. The sources below were opened on November 6, 2026.
| Program | What CMS says | ADR window |
|---|---|---|
| RAC | CMS Recovery Audit Program page: complex and automated post-payment reviews. Regions 1 to 4 review Part A and Part B claims. Region 5 is dedicated to durable medical equipment, prosthetics, orthotics and supplies, and home health and hospice. | 45 calendar days |
| UPIC | CMS Review Contractor Directory: UPICs perform fraud, waste, and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims. | 30 calendar days |
| TPE | CMS Targeted Probe and Educate page: MACs work one-on-one with providers to identify and correct errors. A traditional round generally consists of 20 to 40 claims. | 45 calendar days for a MAC request |
CMS says a RAC issues an Additional Documentation Request (ADR) to obtain the record and supporting documentation. CMS also notes on its approved RAC topics page that CMS may require a RAC to review claims based on referrals, and these CMS-Required RAC reviews are conducted outside of the established ADR limits. The page does not define those limits, so this page states none.
CMS says most providers will never need TPE. Problems that fail to improve after 3 rounds of education sessions are referred to CMS for next steps, which may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.
How long do we have to respond to an Additional Documentation Request?
The window is 45 calendar days for a contractor's request and 30 calendar days for a UPIC's request. Those figures are in 42 CFR 405.903 for prepayment review and 42 CFR 405.929 for post-payment review, and the CMS Additional Documentation Request page restates them.
- Late documentation. A contractor may accept documentation received after 45 calendar days for good cause, and a UPIC may do the same after 30. Good cause means situations such as natural disasters, interruptions in business practices or other extenuating circumstances that the contractor deems good cause.
- No response. If a contractor gives notice and time to respond and the documentation does not arrive in a timely manner, 42 CFR 405.930 says the contractor has authority to deny the claim.
- Denied for missing records. Under 42 CFR 405.980, if a contractor denies a claim because it did not receive requested documentation during medical review and the party then requests a redetermination, the contractor must process the request as a reopening.
The sections do not say which date starts the count, so the tracker records the date and deadline printed on each letter. CMS also says the ADR goes to the practice address on file with Medicare, so keep your Medical Review Correspondence Address in PECOS current; for enrollment records, see the Medicare enrollment program.
What are the appeal deadlines after a RAC or UPIC finding?
Appeal deadlines run 120 calendar days for a redetermination, 180 for a reconsideration, and 60 each for the ALJ hearing, Council review and federal court filing. The table follows the eCFR text current on November 4, 2026 (title 42 last amended October 8, 2026). Your counsel confirms which clock applies to your case.
| Level | Filing deadline | Source |
|---|---|---|
| Redetermination (by the contractor) | 120 calendar days from the date a party receives the notice of the initial determination. Receipt is presumed 5 calendar days after the date of the notice, unless there is evidence to the contrary. After the 120 days, a party may ask the contractor in writing to extend, and the contractor may extend if the party shows good cause. | 405.942 |
| Reconsideration (by a Qualified Independent Contractor, QIC) | 180 calendar days from the date the party receives the notice of the redetermination, with the same 5-day presumption. A QIC may extend for good cause, and the extension request is filed with the reconsideration request. A separate rule covers a contractor's dismissal of a redetermination request. | 405.962 |
| Administrative law judge (ALJ) hearing | 60 calendar days from the date the party receives notice of the QIC's reconsideration. For an appeal of a statistical sample or extrapolation, the request for all sampled claims the appellant wishes to appeal is due within 60 calendar days of receipt of the last reconsideration for the sample claims, if they were not all addressed in a single reconsideration. | 405.1014 |
| Medicare Appeals Council review | 60 calendar days after receipt of the ALJ's or attorney adjudicator's decision or dismissal, with a 5-day receipt presumption. | 405.1102 |
| Federal district court | Within 60 calendar days after the date the party receives notice of the Council's decision. Court review requires that the amount remaining in controversy satisfies section 405.1006(c). | 405.1130, 405.1136 |
Two rules shape the first response. Under 42 CFR 405.966, absent good cause, failure to submit all evidence, including documentation requested in the notice of redetermination, before the notice of reconsideration is issued precludes later consideration of that evidence. Under 42 CFR 405.379, for post-payment denials of Part A and Part B claims that can be appealed through the Medicare claims appeal process, a contractor can begin recoupment no earlier than 41 days from the date of the initial overpayment demand and must cease recoupment on receipt of a timely and valid request for redetermination or reconsideration. If the provider appeals further, to an ALJ, the Council or federal court, recoupment remains in effect as provided in section 405.373(e). Recoupment may resume after a redetermination or reconsideration decision under the conditions in paragraphs (e) and (f).
Who needs an audit response program, and what triggers it?
Providers that receive Medicare review letters need a way to answer them on time. These events start the work.
- An ADR, prepayment review or TPE round arrives and no one owns the response.
- Letters from several contractors reach different departments with different deadlines.
- A new topic appears on the monthly RAC topic page for a service line you bill.
How IHS helps
Thomas G. Goddard, JD, PhD, IHS founder and former URAC Chief Operating Officer and General Counsel, leads the work. This program sits in the Compliance Services practice line.
What IHS drafts
- A request-intake log that records each letter on the day it arrives, with the contractor type, claims, records requested and stated deadline.
- A deadline calendar with the ADR window from each letter and the appeal clocks from each notice, plus an internal due date set before each one.
- A record-assembly checklist that follows CMS guidance: the ADR letter attached as the first page, documentation matched to the patient and claim, and a check for documentation that predates the review period.
- A root-cause review form, a PECOS address check and a monthly check of the RAC topic pages.
What you supply
You supply the letters, the medical records, the clinical documentation review and your appeal counsel.
The real limit
IHS builds the process. Counsel handles appeals. IHS does not respond to the contractor, request extensions or communicate with CMS.
What to have ready
Gather these before the first session.
- Every open review letter, with the deadline printed on each one.
- The contractor name and type on each letter: RAC, UPIC or MAC.
- For each RAC letter, whether the review is automated or complex.
- Each ADR, the records it asks for, the records already assembled and how each response was sent: mail, esMD, a MAC portal, fax or media.
- Any denial for missing documentation, and any appeal already filed.
- Notices of initial determination or redetermination, with dates, and any overpayment demand letter.
- Your Medical Review Correspondence Address in PECOS.
- The name of your appeal counsel and the person who will check the RAC topic pages each month.
With the list in hand, the free introductory call is where IHS walks through it with you.
How it compares
| Option | What it covers | Note |
|---|---|---|
| Internal tracking only | Your own log and calendar. | Works when one person owns every letter and clock. |
| Counsel-led response | Counsel handles contractor contact and appeals. | IHS leaves appeals to your counsel under every option. |
| IHS-built program | Log, calendar, checklists and review form. | Built to be run by your staff. |
| Medicare Advantage and Part D sponsor audits | A different program. | See CMS program audit readiness. |
What it costs
- Authority fees. The CMS pages and regulation sections reviewed for this page state no fee for responding to a documentation request. Verify any filing cost with the office named in your notice.
- Consulting fees. IHS scopes each engagement after a free introductory call. The scope depends on the number of contractors and open letters, how many departments receive them, and whether a log and an owner already exist.
What this is not
- It is not legal advice. IHS is a consulting firm, not a law firm.
- It is not a guarantee of any outcome in a review or an appeal.
- It is not a coding audit or a clinical documentation review of your claims.
Frequently asked questions
What is a Medicare RAC review?
A RAC review is a post-payment review of a Medicare claim by a Recovery Audit Contractor. CMS says automated reviews occur at the system level, while complex reviews require a qualified individual to review the medical record.
What is an Additional Documentation Request?
An Additional Documentation Request, or ADR, is generated when documentation is necessary to support a Medicare claim. CMS says a RAC issues one to obtain the medical record.
How long do we have to respond to an ADR?
The regulation gives 45 calendar days for a contractor's request and 30 calendar days for a UPIC's request, in prepayment review (42 CFR 405.903) and post-payment review (42 CFR 405.929). Your tracker records the deadline printed on each letter.
What happens if we miss the ADR deadline?
If the contractor gave notice and time to respond and the documentation did not arrive in a timely manner, the contractor has authority to deny the claim (42 CFR 405.930). Your counsel advises on next steps.
How long do we have to appeal a finding?
A redetermination must be filed within 120 calendar days from the date you receive the notice of the initial determination (42 CFR 405.942). Later levels run 180 calendar days, then 60 calendar days each. Your counsel confirms the clock for your case.
Does an appeal stop recoupment?
For the overpayments that 42 CFR 405.379 covers, such as post-payment denials of Part A and Part B claims, a timely and valid request for redetermination or reconsideration stops recoupment until the decision, and the section sets conditions for resuming it afterward. Recoupment remains in effect during later appeals as provided in 42 CFR 405.373(e). Counsel confirms whether your overpayment is covered.
How do we find the topics RACs review?
CMS says RAC review topics are updated monthly on its RAC reviews topic page, which lists the review type, provider types, affected codes and applicable policy references.
Does IHS handle appeals or respond to the contractor?
No. Your counsel handles appeals, and your staff handle every contact with a contractor. IHS does not respond to a contractor, request an extension or communicate with CMS.