CMS Pub. 100-08, ch. 3, § 3.2

This section applies to MACs, CERT, RACs, SMRC, and Unified Program Integrity

Contractors (UPICs), as indicated.

A. Prepayment and Post-payment Review

Prepayment review occurs when a reviewer makes a claim determination before claim

payment has been made. Prepayment review always results in an “initial determination”.

Post-payment review occurs when a reviewer makes a claim determination after the claim

has been paid. Post-payment review results in either no change to the initial

determination or a “revised determination” indicating that an overpayment or

underpayment has occurred.

B. Prepayment Edit Capabilities

Prepayment edits shall be able to key on a beneficiary's Medicare beneficiary identifier

(MBI), National Provider Identifier (NPI) and specialty code, service dates, and diagnosis

or procedure code(s) (i.e., Healthcare Common Procedure Coding System [HCPCS]

and/or International Classification of Diseases diagnoses codes), Type of Bill (TOB),

revenue codes, occurrence codes, condition codes, and value codes.

The MAC systems shall be able to select claims for prepayment review using different

types of comparisons. At a minimum, those comparisons shall include:

• Procedure to Procedure -permits contractor systems to screen

multiple services at the claim level and in history.

• Procedure to Provider - permits selective screening of services that

need review for a given provider.

• Frequency to Time- permits contractors to screen for a certain

number of services provided within a given time period.

• Diagnosis to Procedure- permits contractors to screen for services

submitted with a specific diagnosis. For example, the need for a

vitamin B12 injection is related to pernicious anemia, absent of the

stomach, or distal ileum. Contractors must be able to establish edits

where specific diagnosis/procedure relationships are considered to

qualify the claim for payment.

• Procedure to Specialty Code or TOB- permits contractors to screen

services provided by a certain specialty or TOB.

• Procedure to Place of Service- permits selective screening of

claims where the service was provided in a certain setting such as a

comprehensive outpatient rehabilitation facility (CORF).

Additional MAC system comparisons shall include, but are not limited to the following:

• Diagnoses alone or in combination with related factors.

• Revenue linked to the health care common procedure coding

system (HCPCS).

• Charges related to utilization, especially when the service or

procedure has an established dollar or number limit.

• Length of stay or number of visits, especially when the service or

procedure violates time or number limits.

• Specific providers alone or in combination with other parameters.

The MR edits are coded system logic that either automatically pays all or part of a claim,

automatically denies all or part of a claim, or suspends all or part of a claim so that a

trained clinician or claims analyst can review the claim and associated documentation

(including documentation requested after the claim is submitted) in order to make

determinations about coverage and payment under Section 1862(a) (1) (A) of the Act.

Namely, the claim is for a service or device that is medically reasonable and necessary to

diagnose or treat an injury or improve the functioning of a malformed body member. All

non-automated review work resulting from MR edits shall:

• Involve activities defined under the MIP at §1893(b)(1) of the Act;

• Be articulated in the MAC’s medical review strategy;

• Be designed in such a way as to reduce the MAC’s CERT error

rate or prevent the MAC’s CERT error rate from increasing, or;

• Prevent improper payments identified by the RACs.