Counting the 60-Day Time Period for Medical Review
October 2, 2015 04:46 PM
The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 9323 which provides instructions on counting the 60-day time period for review of claims.
The Medicare Administrative Contractors have been instructed to make a review determination, and mail the review results notification letter to the provider within 60 calendar days of receiving the requested documentation, provided the documentation is received within 45 calendar days of the date of the addition documentation request (ADR).
For claims associated with any referrals to the ZPIC for program integrity investigation, MACs shall stop counting the 60-day time period on the date the referral is made. The 60-day time period will be restarted on the date the MAC received requested input from the ZPIC or is notified by the ZPIC that the referral has been declined.
The medical review contractors will deny a claim if the provider does not respond to an ADR within the specified timeframes. If the denial is appealed, the appeals unit is to send the record to the MR department for a reopening. For claims sent to MR for reopening by the contractor appeals department, the contractor is to begin counting the 60 days from the time the medical records are received in the MR department.
Click here to view the CR.