CMS Pub. 100-08, ch. 7, § 7.2.2.2

Non-medical record reviews uses manual intervention, but only to the extent a reviewer

can make a determination based on information on a claim. It does not require clinical

judgment in review of medical record documentation. Contractors shall only perform a

non-medical record review for denials of related claims and/or no receipt of ADR

documentation where such denials cannot be automated.

7.2.2.3 - Demand Bill Claims Review

(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);

Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013

(Implementation of VMS)

Demand bills are submitted at the beneficiary’s/representative’s request because the

beneficiary disputes the provider’s opinion that the bill will not be paid by Medicare and

requests the bill be submitted for a payment determination. The demand bill is identified

by the presence of a condition code 20. There must be a written request from the

beneficiary to submit the bill, unless the beneficiary is deceased or incapable of signing.

In this case, the beneficiary’s guardian, relative or other authorized representative may

make the request. This includes SNF and HHA demand bills as well as other demand

bills (outpatient) and Third Party Liability Medical Reviews.

7.2.2.4 - Medical Review Reopening

(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);

Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013

(Implementation of VMS)

A MR reopening is a remedial action taken to review and change a final determination or

decision that resulted in either an overpayment or an underpayment, even though the

determination for decision was correct based on the evidence in the record. It is separate

and distinct from the appeals process. The Contractor may choose to reopen a claim for

late documentation. The MR department shall conduct a reopening of claims sent by the

appeals department which meet the criteria in IOM Pub. 100-04, Section 10.3. (1) A

provider failed to timely submit documentation through an Additional Documentation

Request (ADR) (2) Claim was denied because the requested documentation was not

received timely (3) the requested documentation is received after the 45 day period with

or without a request for redetermination or reopening AND (4) The request is filed

within 120 days of the receipt of the initial determination. Do not count more than one

reopening per claim.