CMS Limits the Scope of Review on Certain Claims
August 26, 2015 07:55 AM
The Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (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. This expanded review of additional evidence or issues can result in an unfavorable appeal decision reason different from the original denial reason.
For redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has instructed MACs and QICs to limit their review to the reason(s) the claim or line item at issue was initially denied. Post-payment review or audit refers to claims that were initially paid by Medicare and subsequently reopened and reviewed by, for example, a Zone Program Integrity Contractor (ZPIC), Recovery Auditor, MAC, or Comprehensive Error Rate Testing (CERT) contractor, and revised to deny coverage, change coding, or reduce payment. If an appeal involves a claim or line item denied on a pre-payment basis, MACs and QICs may continue to develop new issues and evidence at their discretion and may issue unfavorable decisions for reasons other than those specified in the initial determination.
CMS will permit a MAC or QIC that conducts an appeal of a claim that was denied on post-payment review because the requested documentation was not submitted, to deny claims on appeal if additional documentation is submitted and it does not support medical necessity.
This clarification and instruction applies to redetermination and reconsideration requests received by a MAC or QIC on or after August 1, 2015. It will not be applied retroactively. Appellants will not be entitled to request a reopening of a previously issued redetermination or reconsideration for the purpose of applying this clarification on the scope of review.
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