CMS Limits Scope of Review on Some Redeterminations and Reconsiderations

The Centers for Medicare and Medicaid Services (CMS) issued a revision on May 9, 2016, to a Special Edition of MedLearn Matters (SE1521 Revised).  It deals with a new limit placed on the amount of discretion CMS will allow to Medicare Administrative Contractors (MACs) at the first-level appeals (Redetermination).  Importantly, CMS noted in this document that this guidance also applies to Qualified Independent Contractors (QICs) who review second-level appeals.

As background, CMS has generally allowed MACs and QICs wide discretion when conducting reviews and appeals; each could “develop new issues and review all aspects of coverage and payment related to a claim or line item.”  CMS notes that in some cases, this “expanded review of additional evidence” resulted in unfavorable appeals decisions for a different reason than the initial reason.  In the SE 1521 revision, which is effective for requests received by a MAC or QIC on or after April 18, 2016, CMS outlined the new limits:

  • … For redeterminations and reconsiderations of claims denied following a complex prepayment review, a complex post-payment review, or an automated post-payment review by a contractor, CMS has instructed MACs and QICs to limit their review to the reason(s) the claim or … issue was initially denied …”.

This guidance makes it clear that MACs and QICs retain the ability to develop new issues in other situations.

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