CMS Revises the Claims Reconsideration Process

WASHINGTON, D.C. (May 12, 2016)—Today CMS published a revision to SE1521, which places limits on the scope of review for redeterminations and reconsiderations of certain claims. When this was originally published in 2015, AAHomecare worked with CMS to have the instruction expanded to include complex prepayment audits.

This should be helpful as suppliers work through the audit and appeal process!

Original Text from 2015 (MLN Matters SE1521):
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.

Revised Text, Effective 04/18/16 (MLN Matters SE1521, revised):
For redeterminations and reconsiderations of claims denied following a complex prepayment review, a complex post-payment review, or an automated post-payment review by a contractor, CMS has instructed MACs and QICs to limit their review to the reason(s) the claim or line item at issue was initially denied. Prepayment reviews occur prior to Medicare payment, when a contractor conducts a review of the claim and/or supporting documentation to make an initial determination.

Visit aahomecare.org for more information.