US · guidance
CMS Pub. 100-08, ch. 1, § 1.3.5
Types of Claims for Which Contractors Are Responsible
A. MACs
The MACs should, at their discretion perform medical review functions for all claims
appropriately submitted to them.
Although they will continue to perform a number of quality functions, quality
improvement organizations (QIOs) will no longer be performing the majority of
utilization reviews for acute inpatient prospective payment system (IPPS) hospital and
long-term care hospital (LTCH) claims. The review of acute IPPS hospital and LTCH
claims (which, for the purposes of this section, also includes claims from any hospital
that would be subject to the IPPS or LTCH PPS had it not been granted a waiver) is now
the responsibility of the ACs and MACs. An exception occurs when a provider requests
a higher-weighted diagnosis related group (DRG) review from the QIO. The QIO will
continue to perform those reviews. QIOs will also continue to perform reviews related to
quality of care and expedited determinations.
The MACs shall include claims for which they are responsible when performing data
analysis to plan their medical review strategy. Amendments to plans and strategies shall
be made as needed if analysis indicates adjustment of priorities.
B. CERT
The CERT review contractor is responsible for reviewing claims randomly selected by
the CERT statistical contractor.
C. Recovery Auditors
In general, Recovery Auditors are responsible for reviewing claims where improper
payments have been made or there is a high probability that improper payments were
made.
D. SMRC
Medical review will be performed on Part A, Part B, and DME providers and suppliers as
directed by CMS.
History
(Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
76eb3e3550bb3da32b62edaf0833f0b668e9d378aa1bb885573b21a7c0b98bf2
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