As we see and hear, Medical Review activity is on the rise. To help prepare, QRM’s VP of Medical Review and Clinical Reimbursement has provided the below guidance on a few critical aspects of importance for your organization.
Address on File
Verifying the provider address on file is essential to receipt of medical review correspondence routed via mail. Changing the Provider Address in Fiscal Intermediary Standard System
Medical Review sends Additional Development Request (ADR) letters to request medical records for review. At times, the provider address is no longer current, and the ADR letters are returned as undeliverable.
Address changes and provider file updates must be reported via the Internet-based Provider Enrollment Chain and Ownership System (PECOS), https://pecos.cms.hhs.gov/pecos/login.do#headingLv1. The preferred method for submitting initial applications or making address changes to your provider file is through Internet-based PECOS.
You may also print the electronic versions of the Medicare Enrollment Application CMS-855A form from the Centers for Medicare & Medicaid (CMS) website, https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855a.pdf. There are two address areas on the CMS-855A form; Master and Other. The ADR is automatically generated from the Other Address in FISS. Please ensure the Other Address reflects the address where ADRs should be mailed. Make sure all required fields are completed and the appropriate signature is submitted.
Supplemental Medical Review Contractor
Noridian Healthcare Solutions, LLC, currently contracts with CMS to serve as the Supplemental Medical Review Contractor (SMRC) (https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/SMRC)
The SMRC conducts nationwide medical reviews of Medicaid, Medicare Part A/B, and DMEPOS claims to determine whether claims follow coverage, coding, payment, and billing requirements.
For ease of identification, the SMRC will mail Additional Documentation Request (ADR) letters in green envelopes to providers selected for review.
Humana Code Pair Edit Denials
Providers may now to able to address code pair edit denials through resubmission of claims to Humana for processing.
According to Humana, it will reprocess claims that were denied based on the edits dating back to January 1, 2020, if a provider resubmits the claim (https://www.apta.org/news/2021/02/17/humana-lifts-ncci-edits).
Let's Get to the Point:
Be informed of available resources for successful management of medical review activity. Please forward questions/inquiries to QRM’s Medical Review team, email@example.com.