CHA News Article

CMS Instructs MACs, RACs to Make Claim Review Determinations Within 30 Days

The Centers for Medicare & Medicaid Service (CMS) has announced changes to the instructions for determinations on prepayment reviews by the Medicare Administrative Contractors (MACs) and post-payment reviews by the Recovery Audit Contractors (RACs). The contractors, who currently have up to 60 days to make a claim review determination, must now complete them within 30 calendar days. The attached transmittal instructs MACs on a number of specific steps they must take within 30 days for prepayment routine reviews, prepayment complex reviews and prepayment documentation compliance reviews.

For third-party liability claims, the MAC has 60 days to make a review determination. For post-payment reviews, the MAC retains the 60-day requirement to make a review determination. The RACs, however, must make, document and communicate to the provider the results of a review determination within 30 days. The guidance is effective Feb. 24, 2015.