Medical Review FAQs - JE Part A

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. Why have I not received Additional Documentation Requests (ADRs)?
A2. When a claim is selected for medical review, the ADR is generated and can be seen in DDE and/or it is mailed as a letter to the provider. Letters are sent to the Correspondence address on file in PECOS (Provider Enrollment, Chain and Ownership System) online enrollment site.
To make changes to where and how your facility receives ADRs, contact the provider contact center at 855-609-9960.
For more information, visit the following websites:

• How Do I Check DDE for an ADR?
• Documentation Requests: How, Who and When to Send

Q3. How do I respond to an ADR by FAX?
A3. Here are some tips that will help avoid errors when responding to an ADR by FAX:

• Place the individual claim ADR letter before, i.e., on top of, the claim documentation when faxing.
• Submissions with larger page numbers may need to be split into multiple faxes. Include the claim ADR letter on top of each fax for the claim.

For documentation submission options and further instructions, visit How to Respond to ADR.