Recovery Auditor Determination Decision Tree

Providers may use the below decision tree to determine the correct action to take when the Recovery Auditor has reviewed a claim.

Did the Recovery Auditor Request Records?

   

Providers have 45 calendar days from the date of the request to submit medical records.

Were medical records submitted within 45 days?

   

Recovery Auditor will issue the Review Results Letter to the provider. The letter will not communicate the improper payment amount or the claim appeal rights. The Review Result Letter will start the discussion period timeframe for complex reviews.

Did the findings result in a claim adjustment?

   

The Recovery Auditor will submit the claim for adjustment through the Medicare Data Center. The MAC will process the claim to completion and issue a demand letter.

Provider agrees with the Recovery Auditor findings?

   

No action is needed as the Recovery Auditor agreed with provider's billing.

Provider must send the claim refund to the MAC.

Providers have three options.

  1. Providers may submit additional information to the Recovery Auditor during the discussion period. The discussion period is 40 days from receipt of the demand Letter for automated reviews and 40 days from receipt of the Review Results Letter for complex reviews.
  2. Providers may submit a rebuttal to Noridian documenting why the overpayment will cause financial hardship within 15 days of the date of the demand letter.
  3. Providers may submit a redetermination within 120 days of the demand letter.

Recovery Auditor will issue the Review Results Letter to the provider. The letter will not communicate the improper payment amount or the claim appeal rights. The Review Result Letter will start the discussion period timeframe for complex reviews. The MAC will deny the claim on day 46. The MAC will process the claim to completion and issue a demand letter.

Provider agrees with the Recovery Auditor findings?

   

No action needs to be taken.

The provider must submit a reopening to the MAC with the medical records to support the services.

Recovery Auditor will issue the Review Results Letter to the provider for the automated review. The letter will not communicate the improper payment amount or the claim appeal rights.

Did the findings result in a claim adjustment?

   

The Recovery Auditor will submit the claim for adjustment through the Medicare Data Center. The MAC will process the claim to completion and issue a demand letter. The demand letter will start the date for the discussion period on automated reviews.

Provider agrees with the Recovery Auditor findings?

   

No action is needed as the Recovery Auditor agreed with provider's billing.

Provider must send the claim refund to the MAC.

Providers have three options.

  1. Providers may submit additional information to the Recovery Auditor during the discussion period. The discussion period is 40 days from receipt of the demand Letter for automated reviews and 40 days from receipt of the Review Results Letter for complex reviews.
  2. Providers may submit a rebuttal to Noridian documenting why the overpayment will cause financial hardship within 15 days of the date of the demand letter.
  3. Providers may submit a redetermination within 120 days of the demand letter.
 

Last Updated Thu, 30 Apr 2020 17:04:06 +0000