Pembrolizumab - Service Specific Targeted Review Notification - JE Part A

CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Noridian’s priority is to minimize potential future losses to the Medicare Trust Fund by preventing inappropriate Medicare payments. This is accomplished through provider education, training, and the medical review of claims. A post-payment review has been initiated based on data analysis.

This article is to notify providers of the initiation of a Service Specific Review on:

• HCPCS J9271 - Injection, pembrolizumab, 1 mg

One-Time Notification to Providers

If your facility is selected for this post payment review, you will be notified of the selected claims per an individual letter. Federal law requires that providers submit medical record documentation to support claims for Medicare services upon request. Providers are required to send supporting medical records to the MAC. Authorization for the collection of this informational is included in Federal Law a Social Security Act §§ 1815(a), 1833(e), and 1862(a)(1)(A) and in the Federal Regulation at 42 Code of Federal Regulations (CFR) § 424.5(a)(6).

Provider Action Required

• Review the requested information in the Additional Documentation Request (ADR)
• Locate and submit all requested items in the ADR
• Refer to individual letter for timeline and submission methods

Noridian MR Determination

MR will review the claim documentation within 60 days of its receipt and will determine whether or not the services billed are reasonable and necessary per Medicare coverage requirements. Overall results of the service specific review will be posted to the Noridian website at the end of the review. Noridian will not post provider specific results on the website.