Wednesday, September 3, 2014

CMS Allows MACs and ZPICs to Deny Related Claims

Dianne De La Mare

In August, the US Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) released Transmittal 534 that revises the Medicare Program Integrity Manual to allow the Medicare Administrative Contractors (MACs) and the Zone Program Integrity Contractors (ZPICs) the discretion to deny “related” claims submitted by another provider or supplier. CMS has stated that “if documentation associated with one claim can be used to validate another claim, those claims may be considered related.”

Transmittal 534 also states that MACs and ZPICs have “the discretion to deny other ‘related claims’ submitted before or after the claim in question, subject to CMS approval.” This new policy appears to broaden the scope of claims that may be subject to prepayment and postpayment review and is effective on September 8, 2014.

By way of background, CMS Transmittal 534 appears to replace the CMS Transmittal 505, issued February 5, 2014 and effective March 6, 2014, to authorize all contractors who process and review Medicare claims – including Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), Comprehensive Error Rate Testing (CERT) Auditors, and Recovery Auditors (RACs) – to deny “related” claims submitted by another provider or supplier.

To obtain a copy of Transmittal 534 go to

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