CMS Pub. 100-08, ch. 7, § 7.1.2.6.1

The IPRS shall include a section that describes the process used to monitor budget and

workload for the MR activities definitions. The process shall ensure that spending is

consistent with the allocated budget and include procedures to revise or amend the plan

when spending is over or under the budget allocation. The MAC shall have a table in the

IPRS identifying the MR workload for the current period of performance.

The MAC shall assess the cost effectiveness of each MR activity and appropriateness of

each MR activity. The MAC shall determine if the resources required for the planned

MR activity can contribute to achieving the reduction of the improper payment error rate.

In addition, the IPRS shall describe how workload for each MR activity is accurately and

consistently reported. The workload reporting process shall also assure the proper

allocation of employee hours required for each MR activity.

7.1.2.6.1.1 – Workload Reporting Tables

(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)

The following tables shall be included in the IPRS:

Medical Review Program Workload A/B MAC and HHH MAC

Statement

of Work

(SOW)

MR Activity

Part A

Projected

Workload

for this

Period of

Performance

Part B

Projected

Workload

for this

Period of

Performance

Home Health

Projected

Workload

for this

Period of

Performance

Hospice

Projected

Workload

for this

Period of

Performance

C.5.12.1.6 Defending MR

Decisions at ALJ

Hearings

C.5.12.2.1 Automated

Medical Review

C.5.12.2.2 Non-Medical

Record Review

C.5.12.2.3 Demand Bill

Claims Review

C.5.12.2.4 Medical Record

Review

Reopening

C.5.12.2.5 Prepay Provider

Specific Medical

Record Review

C.5.12.2.6 Prepay Service

Specific Medical

Record Review

C.5.12.2.7 Prepay Probe

Provider Specific

Medical Record

Review

C.5.12.2.8 Prepay Probe

Service Specific

Medical Record

Review

C.5.12.2.10 Postpay Probe

Provider Specific

Medical Record

Review

C.5.12.2.11 Postpay Probe

Service Specific

Medical Record

Review

C.5.12.2.12 Postpay Provider

Specific Medical

Record Review

Statement

of Work

(SOW)

MR Activity

Part A

Projected

Workload

for this

Period of

Performance

Part B

Projected

Workload

for this

Period of

Performance

Home Health

Projected

Workload

for this

Period of

Performance

Hospice

Projected

Workload

for this

Period of

Performance

C.5.12.2.13 Postpay Service

Specific Medical

Record Review

C.5.12.2.17 Externally

Directed

Reviews

C.5.12.2.18 Provider

compliance

Group Directed

Reviews

C.5.12.2.20 One on One

Education

Medical Review Program Workload DME MAC

SOW

MR Activity

Projected workload

for this Period of

Performance

4.7.1 Automated Medical Review

4.7.2 Non-Medical Record Review

4.7.3 Demand Bill Claims Review

4.7.4 Medical Record Review Reopening

4.7.5 Prepay Provider Specific Medical Record Review

4.7.6 Prepay Service Specific Medical Record Review

4.7.7 Prepay Probe Provider Specific Medical Record

Review

4.7.8 Prepay Probe Service Specific Medical Record

Review

4.7.10 Postpay Probe Provider Specific Medical Record

Review

4.7.11 Postpay Probe Service Specific Medical Record

Review

4.7.12 Postpay Provider Specific Medical Record Review

4.7.13 Postpay Service Specific Medical Record Review

4.7.17 Externally Directed Reviews

4.7.18 Provider Compliance Group Directed Reviews

4.7.22 One on One Education

4.12 Defending MR decisions at ALJ Hearings