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Experience. Integrity. Advocacy.

CMS Limits the Scope of Review on Redeterminations of Certain Claims


Starting April 18, 2016, Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) conducting redeterminations and reconsiderations of denied claims must limit their review to the reason the claim or line item at issue was initially denied.

According to the Centers for Medicare and Medicaid Services (CMS), MACs and QICs generally have had discretion while conducting appeals to develop new issues and review all aspects of coverage and payment related to a claim or line item. As a result, in some cases where the original denial reason was cured, the expanded review of additional evidence or issues resulted in an unfavorable appeal decision for a different reason.

Limited Scope for Some Denials

This new guidance will limit the scope of redeterminations only for claims or line items denied during the following types of review: complex prepayment reviews, complex post-payment reviews, or automated post-payment reviews by a contractor. If an appeal involves a claim or line item denied on an automated 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.

For favorable appeal decisions, contractors will continue to follow existing procedures, and adjustments will process through CMS systems. If a claim is suspended due to additional system edits or if a claim adjustment does not process because of additional payment limits (i.e. frequency limits or Correct Coding Initiative edits), new denials may occur with full appeal rights.

Other Exceptions

In addition, if a MAC or QIC conducts an appeal of a claim or line item that was denied on pre- or post-payment review because a provider, supplier, or beneficiary failed to submit requested documentation, the contractor will review all applicable coverage and payment requirements for the item or service at issue, including whether the item or service was medically reasonable and necessary. As a result, claims initially denied for insufficient documentation may be denied on appeal if additional documentation is submitted and it does not support medical necessity.

These new restrictions apply to redetermination and reconsideration requests received by a MAC or QIC on or after April 18, 2016, and will not be applied retroactively. For more information, review the MLN Matters article, “Limiting the Scope of Review on Redeterminations and Reconsiderations of Certain Claims.”

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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