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Cross Recovery for Related Claims

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary.

When medical review results in long-standing high error rates, the MAC may request CMS approval to deny "related" claims submitted before or after the claim in question as outlined in the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3 This link will take you to an external website.

This notifies providers of the initiation of CMS approved cross recovery of professional claims related to denied institutional facet injection services, CPT codes 64493 – 64495; 64635 – 64636. Providers will be notified of recovery on their professional claims in the form of a remittance advice.

If you have any questions related to the recovery of professional claims, contact medicalreviewpartb@noridian.com.

Last Updated Jul 12, 2016