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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.

As always, if you need assistance, Corcoran Consulting Group can help.  Visit our website or call us to learn more.  You can link to our new App, Corcoran 24/7 via the links below.   (800) 399-6565


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