CMS Pub. 100-08, ch. 3, § 3.7.3.2

This section applies to MACs.

MACs shall consider the following factors when looking at edit effectiveness for

established automated edits:

• Time and staffing needs for review and appeal reviews. MACs

shall implement mechanisms (e.g., manual logs, automated

tracking systems) to allow the appeals unit to communicate to the

MR unit information such as when denial categories are causing

the greatest impact on appeals, the outcome of the appeal, and

• MACs shall maintain and make available to the appropriate CMS

staff documentation demonstrating that they consider appeals in

their edit evaluation process; and specificity of edits in relation to

identified problem(s).

The MACs should note that even an automated edit that results in no denials may be

effective as long as the presence of the edit is not preventing the installation of other

automated edits. The MAC shall provide the claims data necessary to the UPIC to

evaluate the effectiveness of edits implemented at UPIC request. The MACs shall

provide this report on a monthly basis by the 15th business day of each month. This

requirement could also be met by the UPICs retrieving claim data necessary directly from

the EDC if available.

A. Edit Effectiveness for all Other Edits

The MACs shall consider the following factors when looking at edit effectiveness for all

other edits:

• Time and staffing needs for review and appeal reviews. MACs

shall implement mechanisms (e.g., manual logs, automated

tracking systems) to allow the appeals unit to communicate to the

MAC MR unit and the UPIC just specific to UPIC edits

information such as which denial categories are causing the

greatest impact on appeals, and the outcome of the appeal. MACs

shall maintain and make available to CMS documentation

demonstrating that appeal outcomes are considered in their edit

evaluation process;

• Specificity of edits in relation to identified problem(s);

• Demonstrated change in provider behavior, i.e., the MAC can show

a decrease in frequency of services per beneficiary, the decrease in

the number of beneficiaries receiving the services, the service is no

longer billed, or another valid measure can be used to reflect a

change in provider behavior over time;

• Impact of educational or deterrent effect in relation to review costs;

and

• The relative priorities or competing edits in terms of the number of

claims/days/charges.

The MACs shall test each edit before implementation to verify that the edit accomplishes

the objective of efficiently selecting claims for review and to determine the edit’s impact

on workload.