Wednesday, August 26, 2015

CMS Limits Scope of Review on Redeterminations and Reconsiderations

Dianne De La Mare
In a recent MLN Matters No. SE1521, the Center for Medicare & Medicaid Services (CMS) clarifies the authority it gives to the MACs and Qualified Independent Contractors (QICs) regarding the scope of review for redeterminations and reconsiderations for certain claims. Generally, MACs and 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. As a result, in some cases, even where the original denial reason is cured, the expanded review of additional evidence or issues could result in an unfavorable appeal decision for a different reason. 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.

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