On August 13, 2015, the Centers for Medicare & Medicaid Services (CMS) issued instructions to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) regarding the scope of review for redeterminations and reconsiderations. See CMS MLN SE1521. This updated instruction applies to redetermination and reconsideration requests received by a MAC or QIC on or after August 1, 2015 and will not be applied retroactively.
This change will likely result in fewer denials at Redetermination and Reconsideration, thereby relieving some of the ongoing backlog at the Administrative Law Judge review level.
Significantly, MACs and QICs must now limit their review only to “the reason(s) the claim or line item at issue was initially denied.” Previously, MACs and QICs had discretion to develop new issues and review all aspects of coverage related to a denied claim or line item. Providers and suppliers were often frustrated because the original reason for denial had been cured (e.g., lack of documentation), but the claims were then denied for new reasons without any ability to explain or even know the issue prior to the denial.
Additional Information
It should be noted that this change only applies to post-payment reviews or audits, which typically refers to claims that were initially paid, then reopened and reviewed by a Zone Program Integrity Contractor (ZPIC), Recovery Audit Contractor (RAC) or a Comprehensive Error Rate Testing (CERT) Contractor. Appeals involving single claims or line items denied for any reason at pre-payment, or denied post-payment because the provider failed to submit the requested documentation, will still be subject to the previous full review of coverage and payment criteria.
For more information, please refer to the CMS MLN Matters No. SE1521.
