CMS clarifies scope of review on claim redeterminations and post-payment reviews

CMS recently updated its instruction to Medicare administrative contractors (MAC) and qualified independent contractors (QIC) on how to conduct appeals and review aspects of coverage and payments involving previously denied claim. For redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has instructed MACs and QICs to limit their review to the reason(s) the claim or line item at issue was initially denied. This updated instruction applies to redetermination requests received by a MAC or QIC on or after August 1, 2015, and will not be applied retroactively.

Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1521.pdf