Medical Review Frequently Asked Questions (FAQs)

Q1. What are common types of claim submissions?
A1. The following are common types of claim submissions, their descriptions, and the CMS Internet-Only Manual (IOM) references for each:

Prior Authorization

To receive prior authorization, the provider must submit documentation for approval of a proposed service before it is rendered. Failure to comply will result in non-affirmation of the service. Once a service has been performed, existing claim review processes and responses as summarized in this document would apply. For more information, please see CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.10.
For information on Noridian Prior Authorization, select Prior Authorization under the Medical Review heading.

Prepayment Review

Once a service has been rendered, providers under prepayment review will submit documentation for review before receiving an initial determination. This will result in an initial determination. For more information, please see CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.

Postpayment Review

After receiving payment for rendered service, providers may be asked to submit supporting documentation for postpayment review. This may result in recoupment or adjustment of payment. For more information, please see CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.5.

Appeals

An appeal is an independent review of the initial or revised determination. Proceeding with an appeal is the responsibility of the provider. Overall, there are 5 levels of appeal the first being a redetermination. For more information, please see the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 29. For Noridian Appeals, select Appeals under the Browse by Topic heading.

Reopenings

Reopenings are separate and distinct from the appeals process and at the discretion of the MAC. MACs may revise an initial determination. Examples include clerical errors or omissions. If a provider submits a request for a reopening, it will not impact or alter the timeframe for an appeal. For more information, please see CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 34. In addition, a reopening will be performed on a claim that denied for no response, meaning no documentation was returned upon MAC request. The decision rendered on a reopening for no response will be the initial determination. For more information please see CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8.

Q2. What are common errors found during claim reviews?
A2. For education on trending errors found during targeted probe and educate (TPE) and skilled nursing facility (SNF) 5-claim probe and educate reviews, select Medical Record Review Results under the Medical Review heading.
For SNF Demand claim review updates and education, select Pre-payment Review under the Medical Review heading.

Q3. How do I respond to an Additional Documentation Request (ADR)?
A3. Providers have 45 days to submit documentation from the date of the ADR. Noridian recommends submitting documentation for each claim ADR as soon as possible. This helps to avoid no response denials and delays in processing of the claim.

There are multiple ways to submit documentation. For documentation submission options and instructions, select How to Respond to ADR under the Medical Review heading.

Last Updated Jan 24 , 2024