CMS Pub. 100-08, ch. 3, § 3.5.2

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

Case review and development provisions:

The MACs and the SMRC shall not perform postpayment review of unassigned claims. A

claim submitted for a service or supply by a provider who has not accepted the Medicare

fee schedule is an unassigned claim.

• The MACs, SMRC, and UPICs have the discretion to select cases

for postpayment review on a claim -by-claim basis or use statistical

sampling for overpayment estimation.

o When MACs, SMRC, and UPICs conduct claim-by-claim

postpayment review, they shall only collect or refund the

actual overpayment or underpayment amount.

o When MACs, SMRC, and UPICs conduct statistical

sampling for overpayment estimation as specified in PIM

chapter 8, they shall extrapolate the sampling results to the

known universe of similar claims when calculating the

projected overpayment or underpayment amount.

• The MACs, RACs, SMRC, and UPICs have the discretion to

conduct the postpayment review onsite at the provider or supplier’s

location.

• MAC staff shall review their provider tracking system, using RAC

Data Warehouse (RACDW) data, and consult with the UPICs to

ensure non- duplication during the process of selecting providers

for postpayment review.

• To prevent duplicate claim reviews, the MACs, SMRC, and RACs

shall use the RACDW to identify, and exclude from review, claims

that were previously reviewed, or that are under current review, by

another contractor.

• CERT shall duplicate another contractor’s review, when

appropriate, if those claims are chosen as part of a statistically

valid random sample to measure the improper payment rate.

• This instruction does not prevent the UPICs from reviewing a claim

that has been reviewed by another contractor in order to support their

case development or other administrative action.

• When the MACs, CERT, RACs, SMRC and UPICs choose to send

the provider an ADR for a postpayment review, they shall do so in

accordance with PIM chapter 3, §3.2.3.2. The contractors may

grant an extension of the submission timeframes at their discretion

or in accordance with their SOWs.

• The MACs, CERT, RACs, SMRC and UPICs make coverage,

coding, and/or other determinations when re-adjudicating claims.

• The MACs, CERT, RACs, SMRC and UPICs shall document all

incorrectly paid, denied, or under-coded (e.g., billed using a

procedure/supply or other code that is lower than what is supported

by medical documentation) items or services.

• Services newly denied as a result of re-adjudication shall be

reported as positive values.

• Services that were denied, but are reinstated as a result of re-adjudication shall be reported as negative values.

• The MACs, CERT, RACs, SMRC and UPICs shall document the

rationale for denial and include the basis for revisions in each case

(important for provider appeals). MACs, CERT, and UPICs should

include copies of the NCD, coverage provisions from interpretive

manuals, or LCD and any applicable references needed to support

individual case determinations. RACs and the SMRC shall include

detailed rationale as outlined in their SOWs.

• The MACs have the discretion to deny payment without the review

of the claim with a medically unlikely service edit.