CMS Limits Scope of Review on Some Claims

The Centers for Medicare & Medicaid Services (CMS) has narrowed the scope of review for redeterminations and reconsiderations of certain Medicare claims denied following (1) a complex prepayment review, (2) a complex post-payment review, or (3) an automated post-payment review by a contractor.

This clarification applies to redetermination and reconsideration requests received on or after April 18, 2016, by a Medicare administrative contractor (MAC), i.e., a payer, like Novitas Solutions, or a qualified independent contractor (QIC), an entity that review physicians' requests for reconsideration in the appeals process. It will not be applied retroactively.

CMS has instructed Medicare administrative contractors MACs and QICs to limit their review to the reason(s) for which the claim or line item at issue was initially denied.

Generally, MACs and QICs have discretion while conducting appeals to develop new issues and review all aspects of coverage and payment related to a claim or line item. As a result, said CMS, in some cases where the original denial reason is cured, this expanded review of additional evidence or issues results in an unfavorable appeal decision for a different reason.

A couple of points to note:

  • Contractors will continue to follow existing procedures regarding claim adjustments resulting from favorable appeal decisions. These adjustments will process through CMS systems but may not process to payment because of additional system-imposed payment limitations, conditions, or restrictions (for example, frequency limits or Correct Coding Initiative edits). In such a case, an adjustment may result in new denials with full appeal rights.
  • If a MAC or QIC conducts an appeal of a claim or line item denied on pre- or post-payment review because a physician or beneficiary failed to submit requested documentation, the contractor will review all applicable coverage and payment requirements for the item or service at issue, including whether it was medically reasonable and necessary. As a result, claims initially denied for insufficient documentation may be denied on appeal if additional documentation is submitted and it does not support medical necessity.

For more information, see CMS MLN Matters No. SE 1521 Revised. Visit TMAs Medicare webpage for Medicare updates and help. If you experience frequent denials, consider calling on TMA Practice Consulting for a coding and documentation review, check-up, or training.

Published May 14, 2016

TMA Practice E-Tips main page

Last Updated On

May 17, 2016

Related Content

Audits | Medicare