Overpayment Demand Letter is Required to Appeal Decisions from SMRC and RA Contractors

When a Supplemental Medical Review Contractor (SMRC) or Recovery Audit (RA) contractor identifies improper payments, they notify the provider via a determination letter (also referred to as a review results letter).  They also notify CGS to initiate the overpayment process.  Once CGS is notified, the claim is adjusted and a remittance advice and overpayment demand letter is generated.  At that time, if you disagree with the SMRC or RA decision, you may request a redetermination (first level of appeal) within 120 days from the date of the CGS demand letter or remittance advice. It has come to CGS attention that some providers are requesting an appeal upon receipt of the SMRC and RA determination letter and prior to the claim adjustment. If a provider decides to appeal the denial decision, they MUST wait until the CGS demand letter or remittance advice is received.  If an appeal request is submitted prior to the CGS demand letter being issued, it cannot be processed as an appeal since the overpayment does not yet exist.

SOURCE: Source
INDUSTRY NEWS TAGS: Cigna Government Services, MAC J15 Kentucky, MAC J15 Ohio

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