(Medicare Program Integrity Manual)

3.6.3 - Beneficiary Notification  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, RACs, and UPICs, as indicated.  A. General   If a claim is denied through prepayment or postpayment review, the MAC shall notify the beneficiary consistent with the requirements in PIM chapter 3, 3.6.2.3. The MAC shall include limitation of liability and appeals information. Notification can occur via Medicare Summary Notice (MSN). The CERT, RACs, and UPICs are not required to issue beneficiary notices for claims they deny. Instead, CERT, RACs, and UPICs shall comm unicate sufficient information to the MAC to allow the MAC to develop an appropriate beneficiary  notice.   The MACs are required to give notice to Medicare beneficiaries when claims are denied in part or in whole based on application of a LCD. All denials t hat result from LCDs shall provide the MSN message 15.19 in addition to the current applicable message. Message 15.19 states ( IOM Pub. 100-04, chapter 21):   A local coverage determination (LCD) was used when we made this decision. A LCD provides a guide to assist in determining whether a particular item or service is covered by Medicare. A copy of this policy is available from your local intermediary, carrier or (Medicare Administrative Contractor) by calling the number in the customer service information box on page one. You can compare the facts in your case to the guidelines set out in the LCD to see whether additional information from your physici an would change our decision.   The MACs shall make these messages available in Spanish where appropriate. The 15.19 portion of the MSN message states:   Una Determinacin de Cobertura Local (LCD, por sus siglas en ingls) fue utilizada cuando se tom esta decisin. La LCD es una gua que ayuda a determinar si un artculo o servicio en particular est cubierto por Medicare. Una copia de esta pliza est disponible en su intermediario, local o en su empresa de seguros Medicare, o en su Contratista Administrative de Medicare, al llamar al nmero que aparece en la informacin de Servicios al Cliente en la pgina uno. Usted puede comparar los datos de su caso con las reglas establecidas en la LCD para ver si obteniendo informacin adicional de su mdico pudiera c ambiar nuestra decisin.  The MACs shall use the above message in every instance of a prepayment denial where a LCD was used in reviewing the claim. Use this message, and message 15.20 (now for FISS MACs, and when 15.20 is fully implemented for contractors  on the MCS/VMS systems) on both full and partial denials, whether the denial was made following automated, non- medical review, or medical record review. MACs shall not use this message on denials not involving LCDs. For claims reviewed on a postpayment ba sis, include the language exactly as contained in the MSN message above if sending the beneficiary a new MSN. If sending a letter, include the language exactly as contained in the MSN message above. Message 15.20 currently states:   The following policies [insert LCD ID# and NCD#] were used when we made this decision.(Pub.100- 04, chapter 21).   The MACs shall continue to use 15.19 in conjunction with the MSN message 15.20, where 15.19 is applicable. MACs should, at their discretion, combine these messages i f necessary, but 15.19 shall not be deleted.   In the case where the results of claims sampling are extrapolated to the universe, only those beneficiaries in the sample need to be notified. In RAC cases, the RAC and MAC Joint Operating Agreement (JOA) shall  specify what information the RAC will supply to allow the MAC to notify the beneficiary when re -adjudication results in a change to the initial determination.    3.6.4 - Notifying the Provider  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to, MACs, RACs, and UPICs, as indicated.   A. General   At the conclusion of postpayment review, the MACs shall send a Review Results Letter to the provider even if no overpayment determination is made. If the MAC s choose to send a Review Results Letter separately from the demand letter they shall do so within the timeframes listed in PIM chapter 3, 3.3.1.1F. Likewise, the RACs shall issue a Review Results Letter for all audits as outlined in their SOW requirements.   UPICs shall comply with the requirements listed below when issuing Review Results Letters.  Each Review Results Letter shall include:   Identification of the provider or supplier name, address, and NPI;    Reason for conducting the review or good cause for  reopening;    A narrative description of the overpayment situation that states the specific issues involved in the overpayment as well as any recommended corrective actions;    The review determination for each claim in the sample, including a specific explanation of why any services were determined to be non-covered, or incorrectly coded and if others were  payable;    A list of all individual claims that includes the actual non -covered amount, the reason for non- coverage, the denied amounts, unde r/overpayment amounts, the 1879 and 1870 of the Act determinations made for each specific claim, along with the amounts that will and will not be recovered from the provider or supplier;    Any information required by PIM chapter 8, 8.4 for statistical sampling for overpayment estimation reviews;    Total underpayment  amounts;    Total overpayment amounts that the provider or supplier is responsible  for;   Total overpayment amounts the provider or supplier is not responsible for  because the provider or supplier  was found to be without  fault;    MACs shall include an explanation that subsequent adjustments may be made at cost settlement to reflect final settled costs;   An explanation of the procedures for recovery of overpayments including Medicares right to recover overpayments and charge interest on debts not  repaid within 30 days (not applicable to RACs or UPICs);    The providers or suppliers right to request an extended repayment schedule  (not applicable to RACs or  UPICs);    The MACs and UPICs shall include lim itation of liability and appeals information in the provider  notices;    The MACs shall include appeals information in the provider  notices;    The MACs shall include the provider or supplier financial rebuttal rights  under PIM chapter 3, 3.6.5;  and   For MAC Review Results Letter only, a description of any additional  corrective actions or follow -up activity the MAC is planning (i.e., prepayment review, re - review in 6  months).  If a claim is denied through prepayment review, the MACs and UPICs are encouraged to issue a notification letter to the provider but may use a remittance notice to meet this requirement. However, if a claim is denied through postpayment review, the MAC and RAC shall notify the provider by issuing a notification letter to meet this re quirement. The UPIC shall use discretion on whether to issue a notification letter.   The CERT contractor is NOT required to issue provider notices for claims they deny. Instead, the CERT contractor shall communicate sufficient information to the MAC to allow the MAC to develop an appropriate provider notice.  B. MACs   The MACs need provide only high- level information to providers when informing them of a prepayment denial via a remittance advice. In other words, the shared system remittance advice messages are sufficient notices to the provider. However, for medical record review, the provider should be notified through the shared system, but the MAC shall retain more detailed information in an accessible location so that upon written or verbal requ est from the provider, the MAC can explain the specific reason the claim was denied as incorrectly coded or otherwise inappropriate.   C. RACs   For overpayments detected through medical record review, the RAC shall send a review results letter as indicated in the RAC SOW. In addition, the RAC shall communicate sufficient information to the MAC so that the MAC can send a remittance advice to the provider and collect the overpayment.   For underpayments, the RAC shall notify the provider as indicated in the RAC SOW. In addition, the RAC shall communicate sufficient information to the MAC so that the MAC can send a remittance advice to the provider and pay back the underpayment.  D. UPICs   For overpayments detected through medical record review, and after coordination between the UPIC and OIG, the UPIC shall send a review results letter (the MAC sends the demand letter). In addition, the UPIC shall communicate sufficient information to the MAC so that the MAC can send a demand letter to the provider and col lect the overpayment. The UPIC shall use discretion on whether to send the review results letter.   E. Indicate in the Denial Notice Whether Records Were Reviewed   For claims where the MAC or UPIC had sent an ADR letter and no timely response was received, they shall issue a denial and indicate in the provider denial notice, that the denial was made without reviewing the documentation because the requested documentation was not received or was not received within the allowable time frame (1862(a) (1) of the Ac t). This information will be useful to the provider in deciding whether to appeal the decision. When denying the claims, contractors shall use Group Code: CO -  Contractual Obligation and Claim Adjustment Reason Code (CARC) 50 -  these are non -covered services because this is not deemed a medical necessity by the payer and Remittance Advice Remark Code (RARC) M127 -  Missing patient medical record for this service.   For claims where the reviewer makes a denial following medical record review, the reviewer has the discretion to indicate in the denial notice, using Group Code: CO -  Contractual Obligation and Claim Adjustment Reason Code (CARC) 50 -  these are non - covered services because this is not deemed a medical necessity by the payer that the denial was made after review of submitted documentation. This includes those claims where the provider submits documentation along with the claim and the reviewer selects that claim for review.   3.6.5 - Provider Financial Rebuttal of Findings  (Rev. 10365; Issued: 10 -02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to the MACs. It does not apply to Recovery Auditors, CERT, and UPICs.   A. General   Providers or suppliers have the right to submit a financial rebuttal statement in accordance with 42 CFR 405.370-375 following receipt of the review results letter and prior to recoupment of the overpayment. The rebuttal statement and any accompanying evidence must be submitted within 15 calendar days from the date of the results letter unless the MAC staff find cause to extend or shorten the time frame.   B. Review of Financial Rebuttal Statement(s)  Within 15 calendar days of receipt of a financial rebuttal, MAC staff shall consider the statement and any evidence submitted to reach a determinatio n regarding whether the facts justify the recoupment. However, the MAC shall not delay recovery of any overpayment beyond the date indicated in the review results letter in order to review and respond to the rebuttal statement even if the principal of the debt is modified after reviewing the rebuttal statement (See 42 CFR 405.375(a)). The MAC shall provide a copy of the rebuttal request and a copy of the MACs response on the rebuttal outcome to the UPICs.   C. Cost Report  Issues   Because of the cost report relationship to the overpayment, it is important to note that the projected overpayment recovered from a provider as a result of a postpayment review using statistical sampling for overpayment estimation is based on the interim p ayment rate in effect at the time of the review.   3.6.6 - Review Determination Documentation Requirements  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, Recovery Auditors, and UPICs, as indicated.