SNF Demand Review Notification - JE Part A

Noridian performs pre-payment review in accordance with the Centers for Medicare & Medicaid Services (CMS) Progressive Corrective Action (PCA) Plan. Noridian Part A Medical Review (MR) is responsible for conducting these audits to ensure that Medicare claims have been billed and paid appropriately. CMS mandates review of SNF demands. Claims will be selected with following criteria:

• Type of bill 21x
• Billed with Condition Code 20

This is a one-time notification to providers. Your facility will be notified of the selected claims per your normal Additional Documentation Request (ADR) process. This may be via a mailed ADR letter and/or Direct Data Entry (DDE). The provider agreement to participate in the Medicare program requires all documentation necessary to support the services billed on the claim to be submitted.

Submit the applicable documentation requested for each claim with a copy of the ADR as a coversheet. Records should be mailed to the address listed on the ADR within 30 days of receipt or a claim denial will occur. Denials may be appealed through the normal appeal process.

Medical Review 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. Along with the claim determination, MR will make a determination of liability for services and whether you are without fault for overpayments. Results of the probe will be posted to the Noridian website following completion of the review process.