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CMS Limits Scope Of Review On Certain Claims

Posted on Wednesday, August 26, 2015 3:04 PM

Until now, Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) have had discretion to develop new issues and review all aspects of coverage and payment related to a claim or line item, while conducting appeals. This expanded review of additional evidence can result in an unfavorable appeal decision reason different from the original. CMS has now issued new guidelines for redeterminations and reconsideration requests received by a MAC or QIC on or after August 1, 2015. Appellants will no longer be entitled to request a reopening of a previously issued redetermination or reconsideration. For any redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has notified MACs and QICs to limit their review to the reason(s) the claim at issue was initially denied. Click here to read more.  

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