Who Reviewed My Claim - JF Part A
Who Reviewed My Claim
Multiple CMS contractors, identified below, are charged with completing reviews of medical record and each send out their own demand letter. It is important for providers to review the letter closely as most times the reviewing entity is indicated within body of letter. Check out the sample additional documentation letters below.
TOB Quick Reference
The following will assist a provider in reviewing the Type of Bill (TOB) on the Remittance Advice (RA) and/or Direct Data Entry (DDE) system to determine which contractor reviewed a claim.
- If TOB equals XX1-8 or XXI, the responsible contractors are Noridian Medical Review, Unified Program Integrity Contractor (UPIC) or Office of Inspector General (OIG)
- If TOB equals XXH, the responsible contractors are Comprehensive Error Rate Testing (CERT) or Recovery Audit Contractor (RAC)
- If TOB equals XXP, the responsible contractor is Quality Improvement Organization (QIO)
Comprehensive Error Rate Testing (CERT)
If a provider receives a letter that looks like the below, the CERT Review Contractor is performing a review. This is not a Noridian review.
Noridian Medical Review
If a provider receives a letter that looks like the below, Noridian is performing a review.
Office of Inspector General (OIG)
No letter example available
Quality Improvement Organization (QIO)
No letter example available
Recovery Audit Contractor (RAC)
If a provider receives a letter that looks like the below, the RAC is performing a review. This is not a Noridian review.
Supplemental Medical Review Contractor (SMRC)
If a provider receives a letter that looks like the below, the SMRC is performing a review. This is not a Noridian review.
