Guide to Understanding the Limitation of the Scope of Review on Redeterminations and Reconsiderations of Certain Claims

CMS issued MLN Matters® Special Edition Article SE1521 (PDF) to clarify instructions to Medicare Administrative Contractors (MAC) and Qualified Independent Contractors (QICs) regarding the scope of review for redeterminations and reconsiderations. This guide provides further clarification regarding claims or line items that were denied based on a complex review versus claims or line items that are denied based on an automated review. This guide also explains what type of documentation should be submitted with a request for a redetermination when submitting the request to Palmetto GBA.

Complex Review (Medical Record Review)
A complex review is described as a review of a claim for which medical records were requested.

Complex reviews may take place on a pre-payment (before the claim is paid) or postpayment (after the claim is paid) basis. To conduct a complex review, the Medicare contractor sends an additional documentation request (ADR) letter to the provider requesting that they submit the medical records that support the services billed. The denial reason code appended to the claim or line item under the complex review process will begin with the number five (5).

When a redetermination request is received, Palmetto GBA is limited in the scope of the review to only the reason the claim was denied. It is important to note that this limitation does not limit the scope to the specific reason code on the claim. For example, if the denial reason code is related to medical necessity, then the review will be done on the documentation submitted to ensure that all medical necessity requirements have been met. The redetermination decision may then result in a different denial rationale, but would still be relative to the medical necessity regulations.

For claims that are reviewed under the complex review process, providers are encouraged to review the remarks on claim page 4 in the Direct Data Entry (DDE) system to fully understand the reason for denial. When submitting a request for a redetermination, submit the documentation that addresses the reason for denial stated in the remarks as well as the denial reason code.

Automated Review
Automated reviews use claims data analysis to identify improper payments. A review is considered automated when a payment decision is made at the system level using available electronic information, with no manual intervention.

An automated review may take place on a pre-payment (before the claim is paid) or a postpayment basis (after the claim is paid). The denial reason code that is appended to a claim or a line item under the automated review process will begin with a number other than five (5) unless the denial is generated based on an edit that was implemented by the Unified Program Integrity Contractor (UPIC) or related to a Local Coverage Decision (LCD) or National Coverage Decision (NCD). Claim or line item denials initiated as a result of a UPIC edit will begin with the number five (5) and the letter Z (e.g., 5Zxxx).

Automated reviews conducted on a pre-payment review basis that result in a denial (full claim or line item) are subject to a review of the entire medical record for the full claim under the redetermination process. Therefore, the redetermination decision may result in a denial for reasons other than the initial denial. Providers should submit all documentation to support the services billed on the entire claim.

Automated reviews conducted on a postpayment basis that result in a denial (full claim or line item) are subject to the limitations of the scope of review during the redetermination process as described above under the complex reviews. When submitting a request for a redetermination, submit all documentation that addresses the actual reason for denial explained in the reason code narrative.