Q1. When is it acceptable to rebill a claim?
A1. Claims should only be resubmitted if the claim is denied for a processable error such as when a claim rejects for missing, invalid, or incomplete information. If the provider has made an error when submitting the claim or disagrees with the claim decision, a provider should follow the self-service reopening or appeals process to make corrections to the claim or appeal the decision. If a claim is rebilled as a duplicate, it will be denied. Providers who are found to be billing duplicate claims during the review will be educated on the error. If providers continue to submit duplicate claims despite education, program integrity action may be taken. Refer to CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1 - General Billing Requirements, Section 120.

Q2. Why was my facility selected for Medical Review?
A2. Facilities are selected for Medical Review through a data driven process that assists with identifying services, billing patterns, or utilization trends that may benefit from additional review. Medical Review analyzes claim data, national and local error trends, CERT findings, billing utilization patterns, and other CMS directed initiatives to identify potential vulnerabilities and opportunities for provider education. If your facility is selected, it does not mean that any billing errors or concerns have been identified. Selection indicates that the services billed meet criteria established for review and helps ensure claims are supported by the medical record and meet applicable Mediare coverage, coding, billing and documentation requirements.

Q3. What recommendation does Medical Review consider most important for providers to follow?
A3. Medical Review's recommendation is to ensure the medical record clearly supports the services billed. Documentation should clearly show why the service was needed, what care and services were provided, and how the service meets Medicare coverage requirements. By having clear and complete documentation this helps support the service billed and demonstrates medical necessity, which may reduce the chance of denials or additional documentation requests.