Skip over navigation

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, Zone Program Integrity Contractor (ZPIC) or Office of Inspector General (OIG)
  • If TOB equals XXH, the responsible contractors are Comprehensive Error Rate Testing (CERT) or Recovery Auditor
  • 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.

Example of CMS demand letter. Contains logo located left upper corner, provider name and address below CMS logo, identifying information for claim under review including CID # and provider National Provider Identifier (NPI). The first paragraph identifies Comprehensive Error Rate Testing as the reviewing contractor.

Noridian Medical Review

If a provider receives a letter that looks like the below, Noridian is performing a review.

Example of Noridian demand letter. The Noridian logo and address is in the upper left-hand corner, and the provider address is just below the Noridian address and the bar code.

The Noridian return address and the Document Control Number (DCN) that identifies Noridian Medicare Part A as the reviewing contractor is included mid page of the demand letter.

Office of Inspector General (OIG)

No letter example available

Quality Improvement Organization (QIO)

No letter example available

Recovery Auditor

If a provider receives a letter that looks like the below, the Recovery Auditor is performing a review. This is not a Noridian review.

Example of RAC demand letter. Contains CMS logo located left upper corner and the Recovery Auditor Contractor information in the upper right corner. Below the CMS logo is the date, reference ID, provider name and address is included, Provider Transaction Access Number (PTAN), Provider National Provider Identifier (NPI), phone and fax number.

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.

Example of SMRC demand letter. The CMS logo is in the upper left-hand corner and the Project ID is just below that. The first paragraph identifies the Supplemental Medical Review Contractor as the reviewing contractor.

Zone Program Integrity Contractor (ZPIC)

If a provider receives a letter that looks like the below, the ZPIC is performing a review. This is not a Noridian review.

Example of ZPIC demand letter. The Noridian logo is in the upper left-hand corner and the return address is in middle of page two.
 

Last Updated Feb 09, 2018