Medical Review Frequently Asked Questions (FAQs)

Q1. When reviewing IRF claims, does Noridian determine medical necessity for the intensive therapy rehabilitation based on therapy time threshold?
A1. No. In December 2017, all MACs received clarification from CMS to base medical necessity for Inpatient Rehabilitation Facility (IRF) reviews on the entirety of documentation and clinical review judgement for each claim and not base it on any threshold of therapy time. For more information, see CMS Medicare Learning Network (MLN) Matters (MM) Special Edition (SE)17036.

Q2. Is an order required for a medication or is intent to order the medication sufficient?
A1. Per CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section (F) (1), the MAC reviewers "shall accept as a valid order any Part B medications, other than controlled substances, ordered through a qualified e-prescribing system." A qualified e-prescribing system is one that meets requirements in 42 CFR §423.160.

Last Updated Jun 01, 2018