CMS Starts Permitting Automatic Denials of Related Claims
February 20, 2014 03:50 PM
The Centers for Medicare and Medicaid Services (CMS) has issued Change Request (CR) 8425 entitled Removing Prohibition, which will allow contractors to make a determination or take action on claims not under review but related to claims submitted for review.
The MAC, RAC and ZPIC contractors now have the discretion to automatically deny claims submitted that are related to other claims where non-coverage or non-payment decisions have been determined though medical record review.
In the CR, CMS provides the following examples and notes that claims with other scenarios may be considered “related” as well.
An inpatient claim and associated documentation is reviewed and determined to be not reasonable and necessary and therefore the physician claim can be determined to be not reasonable and necessary.
A diagnostic test claim and associated documentation is reviewed and determined to be not reasonable and necessary and therefore the professional component can be determined to be not reasonable and necessary.
This policy change could have significant implications for home health and hospice providers since they often submit multiple claims for a single incident of illness - for example, submitting claims for several episodes for home health services or several months for hospice care.
If the contractor determines one claim does not meet Medicare payment criteria, any related claim could also be denied - such as when an episode is denied because it fails to meet the F2F encounter criteria. Claims for subsequent episodes could also be automatically denied.
Please click here to view the full CR.