CMS revises scope of review on redeterminations and reconsiderations

Friday, May 13, 2016

WASHINGTON – CMS has expanded the limits on the scope of review for redeterminations and reconsiderations to include complex prepayment audits, AAHomecare has announced. CMS’s initial instructions to the MACs and QICs applied the limits to post-payment reviews. AAHomecare worked with CMS on revised instructions that read: “For redeterminations and reconsiderations of claims denied following a complex prepayment review, a complex post-payment review, or an automated post-payment review by a contractor, CMS has instructed MACs and QICs to limit their review to the reason(s) the claim or line item at issue was initially denied. Prepayment reviews occur prior to Medicare payment, when a contractor conducts a review of the claim and/or supporting documentation to make an initial determination.” AAHomecare says the change should be helpful to providers as they work through the audit and appeal process.