Tuesday, May 17, 2016

CMS Announces Medicare Claim Appeals Relief

Dan Ciolek 

The Centers for Medicare and Medicaid Services (CMS) has issued a revised MLN Matters Special Edition article titled “Limiting the Scope of Review on Redeterminations and Reconsiderations of Certain Claims.” Effective for certain Redetermination (Level 1) and Reconsideration (Level 2) appeals received by a Medicare Administrative Contractors (MACs) or Qualified Independent Contractors (QICs) on or after April 18, 2016, MACs and QICs must limit their review to the reason(s) the claim or line item at issue was initially denied. 

In the past, MACs and QICs reviewing Level 1 and Level 2 appeals have had the ability to find new reasons to deny coverage if the original denial reason was overturned. However, these contractors are now prohibited from such activities while conducting redeterminations and reconsiderations of claims denied following 1) a complex prepayment review, 2) a complex post-payment review, or 3) an automated post-payment review by a contractor. It is important to note that this policy does not apply to all claim denials. For example, 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 denials for reasons other than those specified in the initial determination.

This policy will not be applied retroactively. See the article for more details.

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