CHA News Article

CMS Clarifies Scope of Review on Redeterminations, Reconsiderations

The Centers for Medicare & Medicaid Services (CMS) has published a special edition article in MLN Matters about the clarification it has given to Medicare administrative contractors (MACs) and qualified independent contractors (QICs) on the scope of review for redeterminations. For redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has instructed MACs and QICs to limit their review to the reasons the claim or line item at issue was initially denied. However, if an appeal involves a claim or line item denied on a pre-payment basis, MACs and QICs may continue to develop new issues and evidence at their discretion and may issue unfavorable decisions for reasons other than those specified in the initial determination. The clarification and instruction applies to redetermination and reconsideration requests received by a MAC or QIC on or after Aug. 1 and will not be applied retroactively.