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Identifying Which Entity Completed a Part A Claim Review

The following information will assist a provider in reviewing the Type of Bill on the remittance advice and/or Direct Data Entry system to determine which type of contractor reviewed a claim.

TOB Quick Reference

If your TOB equals: Responsible Contractors:
XX1-8 or XXI Noridian Medical Review, PSC or OIG
XXH CERT or Recovery Auditor
XXP QIO

 

Review Entity Description
Comprehensive Error Rate Testing (CERT)
  • Examples of the initial request for records and additional record request are available at CERT Provider Website – Sample Letters This link takes you to an external website.
  • TOB will be noted on the remittance advice and in DDE as xxH TOB.
  • Comment section on page 4 of DDE will list a CID (claim identification) number and the reviewer comments
  • Providers will receive a letter from Noridian if the review was unfavorable. Providers should review the letter closely as the reviewing entity will be identified in the body of the letter.
Medical Review (Noridian)
  • Type of bill (TOB) will be noted on the remittance advice and in Direct Data Entry (DDE) as xx0-8 or xxI TOB.
  • Comment section on page 4 of DDE will state "complex," "provider specific," "service specific," "probe," "targeted," or "documentation compliance review" and then will indicate reviewer's comments and applicable references included in review.
  • Provider may receive a letter explaining the review and outcome or education may be posted on the website
Office of Inspector General (OIG)
  • TOB will be noted on the remittance advice and in FISS as xx1-8 or xxI TOB.
  • A denial reason and rational will be listed in the comment section on page 4 of DDE.
  • Letters will be sent by the OIG contractor initiating the review.
Quality Improvement Organization (QIO)
  • TOB will be noted on the remittance advice and in DDE as xxP TOB
  • Letters will be sent by the QIO contractor initiating the review.
Recovery Auditors
  • Information regarding the letters mailed by the Recovery Auditor may be found on the HDI Frequently Asked Questions webpage This link takes you to an external website.
  • TOB will be noted on the remittance advice and in DDE as xxH TOB.
  • Comment section on page 4 of DDE will indicate a Recovery Auditor adjustment
  • Remittance advice remark code will equal N432 (effective July 2010)
Zone Program Integrity Contractor (ZPIC)
  • TOB will be noted on the remittance advice and in DDE as xx1-8 or xxI TOB.
  • A denial reason and rational will be listed in the comment section on page 4 of DDE.
  • Letters will be sent by the PSC contractor initiating the review.

 

Last Updated Aug 16, 2017