CPT® 86826, 86822, 86817, 86813, 86825, 86821, 86816, 86812; HLA - Histocompatibility Testing Service - Service Specific Probe Review - JE Part B

CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. To meet this requirement, Noridian Part B Medical Review (MR) analyzes national and local data in conjunction with the findings from the Office of Inspector General (OIG) and other CMS contractors such as Comprehensive Error Rate Testing (CERT) and Recovery Auditor (RA) to identify atypical billing. After data analysis, MR must verify if billing problems exist through claim reviews to validate provider compliance with Medicare coverage as well as coding and billing guidelines. If issues are identified, MR then determines the severity of problems and develops interventions to correct the problem.

This article is to notify providers of the initiation of a service specific probe review for HLA - Histocompatibility Testing Services. The article further provides instruction on the use of the Noridian Medical Review website to facilitate proper submission of appropriate records and Medical Review contact information.

Review Criteria

A widespread service specific probe review of all claims billed with HLA-Histocompatibility Testing Services will be initiated.

Additional Documentation Requests (ADR)

Your facility will be notified of the selected claims per your normal ADR process.

Carefully review the ADR and submit all applicable documentation for each claim with a copy of the ADR as a coversheet. Providers may mail (hardcopy or CD) or fax the ADR. Records should be mailed (hardcopy or CD), esMD, or faxed to Noridian within 45 days of receipt or a claim denial will occur. Denials may be appealed through the normal appeal process.

The provider agreement to participate in the Medicare program requires all documentation necessary to support the services billed on the claim to be submitted. If records supporting the services on the claim are located at another facility, as the billing provider, your facility is responsible for obtaining those records for review.

Medical Review of Documentation

Medical Review will assess the claim documentation after its receipt according to CMS timelines and will determine whether or not the services billed are reasonable and necessary per Medicare coverage requirements. Along with the claim determination, Medical Review will make a determination of liability for services and whether you are without fault for overpayments.

The results of this review are not a reflection on your competence as a health care professional or the quality of care you provide to your patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility’s compliance with the required documentation. Furthermore, this review does not guarantee coverage and payment as the claims identified may be subject to other CMS contractor reviews. Results of the review will be posted to the Noridian website following completion of the review process.

To review individual claim comments via the Noridian Medicare Portal, complete the following steps:

• Log into Noridian Medicare Portal
• Choose Claim Status from the menu bar
• On the Claim Status Inquiry page
• Fill in all Provider/Supplier Details
• Select MEDB under Program drop down box
• Fill in all Beneficiary Details
• Fill in Claim Details
• Click the Submit Inquiry button at the bottom of the form
• On the Claim Status Results page
• Choose View Claim
• On the right side of the page will the heading: Related Inquiries
• Choose Noridian Comments
• Scroll down the page and under the Claim Status Line Details the comment will display

Note: If documentation was sent late (>45 days from the date of the ADR), the claim may have been reopened by the examiner. These reviews are not currently available on the portal.

Initial documentation must be sent by fax, mail or esMD. Additional documentation requested can be submitted fax, mail or Noridian Medicare Portal.

If you would like to receive information regarding findings specific to your facility prior to the completion of the review, send an email to medicalreviewpartb@noridian.com. In order to facilitate the response, follow these instructions:

• Complete the Subject line with the following information: Results request for HLA- Histocompatibility Testing Services widespread review
• In the body of the email, include the following elements:
• Your name, title, and telephone number
• The facility name
• NPI Number
• Short description of information you would like to receive
• Indicate if you would like to receive results via phone call, fax or US Mail and include a fax number or mailing address as applicable.

If you have any questions, contact the (JE) Provider Contact Center