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CMS Issues Change Request (CR) 9323

Posted on Tuesday, October 6, 2015 3:30 PM

CMS has issued Change Request (CR) 9323, which provides instructions on counting the 60-day time period for review of claims. The Medicare Administrative Contractors have been instructed to make a review determination, and mail the review results notification letter to the provider within 60 calendar days of receiving the requested documentation, if the documentation is received within 45 calendar days of the data of the additional documentation request (ADR). For any claims associated with referrals to the ZPIC for program integrity investigation, MACs will stop counting the 60-day time period of the data the referral is made. The 60-day time period will be restarted on the date the MAC received requested input form the ZPIC or was notified by ZPIC that the referral has been declined. The medical review contractors will deny a claim if the provider does not respond to an ADR within the specified timeframe. If the denial is appealed, the appeals unit is to send the record to the MR department for a reopening.  For any claims sent to MR for reopening by the contractor appeals department, the contractor is to begin counting the 60 days from the time the medical records have received in the MR department. Click here to see the CR. Click here to read more.

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