---
kind: "section"
citation: "42 C.F.R. § 421.304"
title: "42"
number: "421.304"
heading: "Medicare integrity program contractor functions."
url: "https://uscodex.org/cfr/42/421.304"
---

# §421.304. Medicare integrity program contractor functions.


The contract between CMS and a Medicare integrity program contractor specifies the functions the contractor performs. The contract may include any or all of the following functions:

- (a) Conducting medical reviews, utilization reviews, and reviews of potential fraud related to the activities of providers of services and other individuals and entities (including entities contracting with CMS under parts [417](/cfr/42/part417.md) and [422](/cfr/42/part422.md) of this chapter) furnishing services for which Medicare payment may be made either directly or indirectly.
- (b) Auditing, settling and determining cost report payments for providers of services, or other individuals or entities (including entities contracting with CMS under parts [417](/cfr/42/part417.md) and [422](/cfr/42/part422.md) of this chapter), as necessary to help ensure proper Medicare payment.
- (c) Determining whether a payment is authorized under title XVIII, as specified in section 1862(b) of the Act, and recovering mistaken and conditional payments under [section 1862(b)](/cfr/42/1862.md?p=b) of the Act.
- (d) Educating providers, suppliers, beneficiaries, and other persons regarding payment integrity and benefit quality assurance issues.
- (e) Developing, and periodically updating, a list of items of DME that are frequently subject to unnecessary utilization throughout the contractor's entire service area or a portion of the area, in accordance with [section 1834(a)(15)(A)](/cfr/42/1834.md?p=a-15-A) of the Act.

## Notes

### Source

Source: 72 FR 48886, Aug. 24, 2007, unless otherwise noted.

### Authority

Authority: 42 U.S.C. 1302 and 1395hh.

### Source

Source: 45 FR 42179, June 23, 1980, unless otherwise noted.