Subcontractors Allowed to Deny Claims that are Related

Effective Sept. 8, Medicare Administrative Contractors (MACs) or other audit subcontractors have the discretion to deny other “related” claims submitted before or after a claim in question. If documentation associated with one claim can be used to validate another claim, those claims may be considered “related.” Audit contractors must get approval from CMS to initiate a related claims review or denial using a process outlined in Transmittal R541PI, issued Sept. 12. The transmittal allows MACs and Zone Program Integrity Contractors (ZPICs) to deny related claims submitted before or after a claim that is under review. Recovery auditors (RAs) also may deny related claims, but they must follow a different process. MACs must post their intent to deny related claims on their website one month prior to implementation, after getting CMS approval. Once the month has expired, claims may be denied automatically or after manual review. MACs, ZPICs, and RAs do not need to make additional documentation requests or do any further review to deny a related claim.