August 31, 2015

Claims Redeterminations Clarified by CMS

The Centers for Medicare and Medicaid Services (CMS) have issued clarification regarding post-payment audits and reviews. Post-payment redeterminations and reconsiderations will be limited and based on the reason the claim was initially denied. Appeals regarding claims under prepayment review will continue to find themselves open to the addition of new issues or evidence. This clarification will not be applied retroactively and appellants will not be entitled to a reopening of previously issued redeterminations for the purpose of applying this clarification on the scope of review as this updated instruction applies to redetermination requests received by a MAC or QIC on or after August 1, 2015, see MLN Matters article SE1521 and the Medicare Claims Processing Manual Publication 100-04, Chapter 29 (Appeals of Claims Decisions), Section 310.4.C.1. (Conducting the Redetermination [Overview]) on the CMS website for more details about the appeals process.

Please contact Dominick Parris in the Economics and Health Policy Department with your questions at