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Good News From Our Reimbursement Team: Update to Reviews at Appeals

Posted on in Billing/Reimbursement, HME Government Issues

In an MLN article, SE1521, released August 19, 2015, there was good news for the DMEPOS industry. On post-payment reviews at redeterminations and reconsiderations, the reviews are limited to the reason the claim or line item at issue was initially denied. This applies to ZPIC, RAC, MAC, CERT, post-payment audits. This is for requests received by MAC or QIC on or after August 1, 2015.

That is old news. Here is the latest good news!

In an update released on May 9 to the revised SE1521, this is for claims at redeterminations and reconsiderations for complex pre-payment reviews, complex post-payment reviews and automated post-payment reviews. CMS instructed to limit the review to the reason the claim or line item at issue was initially denied. The instruction applies to DME MAC, ZPIC, RAC and CERT.

Pre-payment reviews occur prior to Medicare payment. Post-payment reviews refer to claims that were initially paid by Medicare and then reopened and reviewed. Automated reviews are claims used to identify improper payment through data analysis. This is for requests received by the MAC or QIC on or after April 18, 2016.

If the review is for a claim in an automated pre-payment review (MAC or QIC), they may continue to develop new issues at their discretion and will issue unfavorable letters.

Again, this is for reviews at the first two level of appeals, redeterminations and reconsiderations, for complex pre-payment reviews, complex post-payment reviews and automated post-payment reviews.

Click here to review the full article.

Reimbursement Team

Ronda Buhrmester                                           Dan Fedor
888-665-6518                                                     844-794-8459
Ronda.Buhrmester@vgm.com                        Dan.Fedor@vgm.com

 

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