CMS Pub. 100-04, ch. 24, § 90.7.4

RRB SMAC

(Rev. 13105; Issued- 04-10-25; Effective: 05-12-25; Implementation: 05-12-25)

Due to the impact of ASCA review decisions made by A/B MACs (B), it would not be

reasonable to require that the RRB SMAC issue new ASCA review letters for 20 percent

of the providers who send them paper bills annually without giving the RRB SMAC

some credit for the additional effort expended as result of the PES-SuperPES-quarterly

paper claim submitters reports reviews the RMC is required to conduct. It takes the RRB

SMAC longer to identify providers that should be sent letters to initiate a new ASCA

review and in some cases, the cross checks performed by the RRB SMAC result in

disqualification of a provider for selection for a new ASCA Enforcement Review. To

adjust for this, the RRB SMAC annual ASCA review target is to review the records of 20

percent of those providers who submit paper claims as indicated in the MCS quarterly

paper claim submitters reports, and not to necessarily initiate a new ASCA review of 20

percent of the providers that send them paper claims annually.

To compute this 20 percent, the total number of providers for whom reviews are to be

conducted shall be computed as directed in §90.5.3. To gauge the number to be reviewed

during a single quarter in the same FY prior to production of the fourth quarterly report

for that FY, the RRB SMAC shall multiply the total of providers who submitted paper

bills in the most recent quarterly report by 0.2 (20 percent), and then multiply again by

.25. The number of reviews to be initiated during the fourth quarter shall be computed by

subtracting the total reviews identified as conducted for the first three quarters of the FY

from the total number of reviews targeted for the FY as a whole; the difference in the

totals is the number of reviews to be started during the fourth quarter.

For purposes of the monthly ASCA review report submitted to DSSMdata.info prior to

the fourth quarter of a FY, the total number of providers in the MCS most recent

quarterly paper claim submitters report shall be entered in the “eligible providers” field.

The total number of providers in that quarterly report for whom ASCA review letters are

actually issued to begin reviews plus those for whom a decision is made that a new

review is not warranted at that time due to an ASCA review action taken by another

Medicare contractor shall be entered in the “Initial Review Letters Issued for Report

Period” field of the monthly DSSMdata.info report. CMS realizes that an initial review

letter will not actually have been issued by the RRB SMAC to each provider in this

second situation, but the RRB SMAC review of ASCA data in SuperPES for those

providers selected from the MCS quarterly paper claim submitters report which result in

decisions not to initiate new reviews will be considered as equivalent to initiation of a

new review by CMS for comparison purposes with A/B MACs (B) and to determine if

the annual 20 percent target has been reached by the RRB SMAC . The number of

ASCA reviews completed total to be entered in the monthly report shall equal the number

of ASCA reviews completed during the reporting period that were initiated with an

ASCA review letter plus the number of new ASCA reviews that were determined not to

be warranted that month as result of review of ASCA information in SuperPES that same

month.

For the fourth quarter of the FY, the total number of providers as computed for the FY

who are eligible for review, i.e., the total who submitted paper claims in each of the

quarterly ASCA reports for the FY divided by four, shall be entered in the DSSMdata.info

monthly report as the number of “Eligible Providers.” The RRB SMAC shall follow the

direction in the prior paragraph to calculate the number of ‘Initial Review Letters Issued

for Report Period” and the “Reviews Completed” totals to be entered in those fields of

the DSSMdata.info reports for the months in that final quarter. The remaining fields of

the monthly ASCA reports are to be completed by the RRB SMAC according to the

existing completion instructions for that report which were previously issued to the

Medicare contractors.