CMS Revises Time Frames for Medical Review Determinations
November 2, 2014 09:47 AM
The Centers for Medicare & Medicaid Service (CMS) has issued Change Request (CR) 8443, which instructs the Medicare claims review contractors that determinations on prepayment reviews for the Medicare Administrative Contractors (MACs) and post- payment reviews by the Recovery Audit Contractors (RACs) must be completed within 30 calendar days. Currently the contractors have up to 60 days to make a claim review determination.
For prepayment reviews: the MAC must do the following within 30 days of receiving documentation from additional documentation requests (ADRs). 1) make and document the review determination and 2) enter the decision into the Fiscal Intermediary Shared System (FISS), Multi-Carrier System (MCS), or the VIPS Medicare System (VMS). The 30 calendar day timeframe applies to prepayment routine reviews, prepayment complex reviews and prepayment documentation compliance reviews. For Third Party Liability claims, the MAC has 60 days to make a review determination.
For post-payment reviews: the MAC retains the 60 day requirement to make a claims review determination. The RACs, however, mustmake, document, and communicate to the provider the results of the review determination within 30 days.
The MACs and RACs are to count day one as the date each new medical record is received in the mailroom and shall give each new medical record received an independent 30 day review time period (when applicable).
The CR also requires that the MACs, Comprehensive Error Rate Testing Contractors, and Zone Program Integrity Contractors ensure that complex reviews for the purpose of making coverage determinations are performed by licensed nurses (RNs and LPNs) or physicians, unless this task is delegated to other licensed health care professionals. The RACs and the Supplemental Medical Review Contractor must ensure that the credentials of their reviewers are consistent with the requirements in their respective SOWs.
Click here to view Change Request 8443.