CMS Pub. 100-08, ch. 3, § 3.3.1.1

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

A. Definition

Medical record review involves requesting, receiving, and reviewing medical

documentation associated with a claim.

Medical record review, for the purpose of determining medical necessity, requires a

licensed medical professional to use clinical review judgment to evaluate medical record

documentation.

B. Clinical Review Judgment

Clinical review judgment involves two steps:

1. The synthesis of all submitted medical record information (e.g. progress notes,

diagnostic findings, medications, nursing notes, etc.) to create a longitudinal clinical

picture of the patient; and

2. The application of this clinical picture to the review criteria is to make a reviewer

determination on whether the clinical requirements in the relevant policy have been met.

MAC, CERT, RAC, SMRC, and UPIC clinical review staff shall use clinical review

judgment when making medical record review determinations about a claim.

Clinical review judgment does not replace poor or inadequate medical records.

Clinical review judgment by definition is not a process that MACs, CERT, RACs,

SMRC, and UPICs can use to override, supersede or disregard a policy requirement.

Policies include laws, regulations, the CMS’ rulings, manual instructions, MAC

policy articles attached to an LCD or listed in the Medicare Coverage Database,

national coverage decisions, and local coverage determinations.

C. Credentials of Reviewers

The MACs, MRAC, and CERT shall ensure that medical record reviews for the purpose

of making coverage determinations are performed by licensed nurses (RNs), therapists or

physicians. Current LPNs may be grandfathered in and can continue to perform medical

record review. The MACs, MRAC, and CERT shall not hire any new LPNs to perform

medical record review. UPICs, RACs and the SMRC shall ensure that the credentials of

their reviewers are consistent with the requirements in their respective SOWs.

During a medical record review, nurse and physician reviewers may call upon other

health care professionals (e.g., dieticians or physician specialists) for advice. The MACs,

MRAC, and CERT, shall ensure that services reviewed by other licensed health care

professionals are within their scope of practice and that their MR strategy supports the

need for their specialized expertise in the adjudication of particular claim type (i.e.,

speech therapy claim, physical therapy). RACs and the SMRC shall follow guidance

related to calling upon other healthcare professionals as outlined in their respective

SOWs.

RACs shall ensure that a licensed medical professional will perform medical record

reviews for the purpose of determining medical necessity, using their clinical review

judgment to evaluate medical record documentation. Certified coders will perform coding

determinations. CERT and MACs are encouraged to make coding determinations by

using certified coders. UPICs have the discretion to make coding determinations using

certified coders.

SMRC shall follow guidance related to certified coders as outlined in their

SOW.

D. Credential Files

The MACs, MRAC, CERT, RACs, and UPICs shall maintain a credentials file for each

reviewer (including consultants, contract staff, subcontractors, and temporary staff) who

performs medical record reviews. The credentials file shall contain at least a copy of the

reviewer’s active professional license.

E. Quality Improvement (QI) Process

The MACs, CERT, RACs, and SMRC shall establish a Quality Improvement (QI)

process that verifies the accuracy of MR decisions made by licensed health care

professionals. The MACs, CERT, RACs, and SMRC shall attend the annual medical

review training conference as directed by the CMS and/or their SOW. The MACs, CERT,

RACs, and SMRC shall include inter-rater reliability assessments in their QI process and

shall report these results as directed by CMS.

F. Advanced Beneficiary Notice (ABN)

The MACs, CERT, RACs, UPICs, and SMRC shall request as part of the ADR, during a

medical record review, a copy of any mandatory ABNs, as defined in Pub. 100- 04,

Medicare Claims Processing Manual Chapter 30 section 50.3.1. If the claim is

determined not to be reasonable and necessary, the contractor will perform a face validity

assessment of the ABN in accordance with the instructions stated in Pub. 100-04

Medicare Claims Processing Manual chapter 30 section 50.6.3.

The Face Validity assessments do not include contacting beneficiaries or providers to

ensure the accuracy or authenticity of the information. Face Validity assessments will

assist in ensuring that liability is assigned in accordance with the Limitations of Liability

Provisions of section 1879 of the Social Security Act.

G. MAC Funding Issues

The MAC-medical record review work performed by medical review staff for purposes

other than MR (e.g., appeals) shall be charged, for expenditure reporting purposes, to the

area requiring medical review services.

All medical record review work performed by MACs shall:

• Involve activities defined under the Medicare Integrity Program

(MIP) at Section 1893(b)(1) of the Act;

• Be articulated in its medical review strategy; and

• Be designed in such a way as to reduce its Comprehensive Error

Rate Testing (CERT) error rate or prevent the contractor’s error

rate from increasing.

The MACs shall be mindful that edits suspending a claim for medical review to check for

issues other than inappropriate billing (i.e. completeness of claims, conditions of

participation, quality of care) are not medical review edits as defined under Section

1893(b)(1) of the Act and cannot be funded by MIP. Therefore, edits resulting in work

other than that defined in Section1893 (b) (1) shall be charged to the appropriate Program

Management activity cost center. Activities associated with claims processing edits shall

not be charged to MIP.

H. Review Timeliness Requirements

Prepayment Review Requirements for MACs

When a MAC receives requested documentation for prepayment review within 45

calendar days of the date of the ADR, the MAC shall do the following within 30 calendar

days of receiving the requested documentation: 1) make and document the review

determination and 2) enter the decision into the Fiscal Intermediary Shared System

(FISS), Multi-Carrier System (MCS), or the VIPS Medicare System (VMS). The 30

calendar day timeframe applies to prepayment non-medical record reviews and

prepayment medical record reviews. The 30 calendar day timeframe does not apply to

prepayment reviews of Third Party Liability claims. The MACs shall make and enter a

review determination for Third Party Liability claims within 60 calendar days.

Counting the 30 Calendar Day Timeframe

The MACs and RACs shall count day one as the date each new medical record is

received in the mailroom. The MACs and RACs shall give each new medical record

received an independent 30 day review time period.

Prepayment Review Requirements for UPICs

When a UPIC receives all documentation requested for prepayment review within 45

calendar days of the date of the ADR, the UPIC shall make and document the review

determination and notify the MAC of its determination within 60 calendar days of

receiving all requested documentation. Medical review for the purpose of fraud, waste, or

abuse requires 60 days to allow for the integration of information from the investigative

process. This information may be a result of recent/concurrent investigative actions such

as beneficiary/provider/supplier interviews, site visits and/or receipt of additional

internal/external information.

Post-payment Review Requirements for MACs

The MAC shall make a review determination and mail the review results notification

letter to the provider within 60 calendar days of receiving the requested documentation.

For claims associated with any referrals to the UPIC for program integrity investigation,

MACs shall stop counting the 60-day time period on the date the referral is made. The

60-day time period will be restarted on the date the MAC received requested input from

the UPIC or is notified by the UPIC that the referral has been declined.

For claims sent to MR for reopening by the contractor appeals department, in accordance

with Pub. 100-04, chapter 34, §10.3, begin counting the 60 days from the time the

medical records are received in the MR department.

Post-payment Review Requirements for RACs

When a RAC receives requested documentation for review within 45 calendar days of the

date of the ADR, the RAC shall do the following within 30 calendar days of receiving the

requested documentation: 1) make and document the review determination, and 2)

communicate the results to the provider.

State Laws that Affect Prepayment Review Timeliness Requirements

The MACs shall adhere to state laws that require an evidentiary hearing for the

beneficiary before any denials are processed. The MAC shall review the claim within 30

days, allow the time required for the evidentiary hearing, and then continue with the

processing of the claim on the next business day.

Post-payment Review Requirements for UPICs

To promote the timeliness of the investigative process, the UPICs shall complete post-payment medical review and provide the lead investigator with a final summary of the

medical review findings that includes reference to the allegations being substantiated/not

substantiated by medical review, reasons for denials, and any observations or trends

noted within 60 calendar days, unless otherwise directed by CMS. The counting for the

60-day time period begins when all of the documentation is received by the UPIC. The

UPIC shall have a HIPAA compliant process to receive this documentation that includes

the application of the date the documents are received at the UPIC’s designated mailing

address for all methods described in section 3.2.3.5 of this chapter. The medical review

unit shall communicate the medical review findings in a summary document to the

investigative lead within 60 calendar days of receiving all of the requested

documentation. Medical review for the purpose of fraud, waste, or abuse requires 60 days

to allow for the integration of information from the investigative process. This

information may be a result of recent/concurrent investigative actions such as

beneficiary/provider/supplier interviews, site visits and/or receipt of additional

internal/external information.

If the UPIC is unable to complete the post-payment medical review in 60 days, they shall

document this and the reason for the delay in the UCM and communicate this to their

COR/BFL.