CMS Pub. 100-08, ch. 3, § 3.2.2

This section applies to MACs, RACs, UPICs, and SMRC as indicated.

Because the CERT contractors select claims on a random basis, they are not required to

notify providers of their intention to begin a review.

Providers may submit unsolicited documentation to the MAC when submitting a claim

for payment. Providers are to list the PWK 02 Report Transmission Code (PWK

(paperwork) modifier) on the claim when submitting this documentation. MACs should

inform the providers that they are NOT required to submit unsolicited documentation

(and the corresponding PWK modifier) and that the absence or presence of PWK

modifier does not mean that their claim will be reviewed. MACs should, at their

discretion, consider posting to their website or sending letters to providers informing

them of what additional documentation is needed to make a determination on the claim.

A. Notice of Provider-Specific Review

When MAC data analysis indicates that a provider-specific potential error exists that

cannot be confirmed without requesting and reviewing documentation associated with the

claim, the MAC shall review a sample of representative claims. Before deploying

significant medical review resources to examine claims identified as potential problems

through data analysis, MACs shall take the interim step of selecting a small "probe"

sample of generally 20-40 potential problem claims (prepayment or post-payment) to

validate the hypothesis that such claims are being billed in error. This ensures that

medical review activities are targeted at identified problem areas. The MACs shall

ensure that such a sample is large enough to provide confidence in the result, but small

enough to limit administrative burden. The CMS encourages the MACs to conduct error

validation reviews on a prepayment basis to help prevent improper payments.

MACs shall select providers for error validation reviews in the following instances, at a

minimum:

• The MAC has identified questionable billing practices (e.g., non-covered, incorrectly coded or incorrectly billed services) through

data analysis;

• The MAC receives alerts from other MACs, Quality Improvement

Organizations (QIOs), CERT, RACs, OIG/GAO, or

internal/external components that warrant review;

• The MAC receives complaints; or,

• The MAC validates the items bulleted in §3.2.1.

Provider-specific error validation reviews are undertaken when one or a relatively small

number of providers seem to be experiencing similar/recurrent problems with billing. The

MACs shall document their reasons for selecting the provider for the error validation

review. In all cases, they shall clearly document the issues noted and cite the applicable

law, published NCD or LCD.

For provider-specific problems, the MAC shall notify providers in writing that a probe

sample review is being conducted. MACs shall consider sending letters to providers

informing them of what additional documentation is needed to make a determination on

the claim.

Generally, MACs shall subject a provider to no more than one probe review at any time;

however, MACs have the discretion to conduct multiple probes for very large billers if

they will not constitute undue administrative burden.

MACs

The MACs shall notify selected providers prior to beginning a provider-specific review

by sending an individual written notice. MACs shall indicate whether the review will

occur on a prepayment or post-payment basis. This notification may be issued via

certified letter with return receipt requested. MACs shall notify providers of the specific

reason for selection. If the basis for selection is comparative data, MACs shall provide

the data on how the provider varies significantly from other providers in the same

specialty, jurisdiction, or locality. Graphic presentations help to communicate the

perceived problem more clearly.

RACs

The RACs are required to post a description of all approved new issues (review topics) to

the RAC’s website before beginning review of the topic and correspondence is sent to the

provider. After posting, the RAC should issue an additional documentation request

(ADR) to the provider, if warranted.

UPICs

The UPICs shall notify selected providers prior to beginning a provider-specific review

by sending an individual written notice. UPICs shall indicate whether the review will

occur on a prepayment or post-payment basis. UPICs shall maintain a copy of the letter

and the date it was mailed. This notification shall be mailed the same day that the edit

request is forwarded to the MAC. Refer to Exhibit 45 for the letter to be sent.

B. Notice of Service-Specific Review

This section applies to MACs, RACs and SMRC as indicated.

Service-specific reviews are undertaken when the same or similar problematic process is

noted to be widespread and affecting one type of service (e.g., providing tube feedings to

home health beneficiaries across three (3) states).

MACs

Website postings

The MACs shall provide notification prior to beginning a service-specific review by

posting a review description on their website. MACs should, at their discretion, state

what additional documentation is needed from providers to make a claim determination

on their website. MACs shall keep the website current by posting active reviews.

MACs should, at their discretion, create an archive for old review topics that are no

longer under active review. Active review is defined as the time period during which

ADRs are sent, determinations are made and findings are communicated to the providers.

MACs should categorize the active review topics by provider type.

Individual written notices

MACs have the discretion to also notify providers about a service-specific review by

sending individual notices to the affected providers. MACs have the discretion to issue

the notice separately or include it in the ADR. MACs should, at their discretion, state

what additional documentation is needed from providers to make a claim determination

in the written notices.

RACs

Before beginning widespread service-specific reviews, RACs shall notify the provider

community that the RAC intends to initiate review of certain items/services through a

posting on the RAC website describing the item/service that will be reviewed.

Additionally, for medical record reviews, the RACs shall send ADRs to providers that

clearly articulate the items or services under review and indicate the appropriate

documentation to be submitted.

UPICs

The UPICs shall provide notification prior to beginning a service-specific review by

sending individual written notices to the affected providers. This notification shall be

mailed the same day that the edit request is forwarded to the MAC. The UPICs shall

maintain a copy of the letter and the date it was mailed. Refer to Exhibit 45 for the letter

to be sent.

SMRC

The SMRC shall operate/maintain a public website that displays what types of issues are

under review. For each area, the SMRC shall include a link to the relevant OIG/GAO or

other reports available. In addition to the website, the SMRC shall notify providers about

a service-specific review by sending an ADR. The SMRC shall state what additional

documentation is needed from providers to make a claim determination in the ADR.