evekhm/cms_iom_500 huggingface dataset:
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 The workload, costs, and savings associated with this activity shall be allocated to the appropriate MR activity (e.g., MR  reopenings);   In cases where the MAC or UPIC denied a claim and the denial is appealed, the appeals entity will send the claim to the contractors MR department for reopening in accordance with CMS Pub. IOM 100- 04, chapter 34,  10.3. The claim sent back to the contractors MR department must have been denied 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 and Remittance Advice Remark Code (RARC) M127 -  Missing patient medical record for this service .  The MR department of the contractor (AC, MAC, or UPIC) who initiated the prepayment edit shall be responsible for conducting the reopening.   The MACs who choose not to reopen claims when documentation is received  past the deadline shall retain the infor mation (hardcopy or electronic) in a location where it can be easily  accessed.   If the RAC receives requested documentation from a supplier after a denial has been issued they shall not reopen the claim.    If a RAC receives documentation after the submissio n deadline, but before they have issued a demand letter, the RAC shall review and consider the late documentation when making a claim  determination;   If the RAC receives a late response to a documentation request after they  have issued a demand letter, the RAC shall retain the documentation so that it is available for review during the appeal  process.   For information on how CERT handles late documentation, please refer to Chapter 12, Section 12.3.9.  3.2.3.10 - Record Retention and Storage  (Rev.  10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  The MACs, CERT, and UPICs shall abide by all documentation retention requirements listed in all litigation holds issued via Joint Signature Memoranda or Technical Direction Letters (JSM/TDL). Recovery Auditors shall comply with the record retention requirements in its SOWs.
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3.2.4 - Use of Claims History Information in Claim Payment Determinations  (Rev. 802; Issued: 06- 22-18; Effective: 07 -24-18; Implementation: 07 -24-18)  A. Contractors to Which This Section Applies   This section applies to MACs, CERT, SMRC, and RACs.  B. General   In certain circumstances it may be appropriate for medical reviewers to use relevant and accessible claims history to assist in making medical record re view determinations. Examples of when this may be used for payment purposes, include, but are not limited to:    1. Reviewers have the discretion to use beneficiary payment history to identify other providers, other than the billing entity, who may have documentation to support payment of a claim.  MAC, CERT and RAC reviewers have the discretion to contact identified providers for supporting documentation. Example: A diabetic beneficiary may have an order from a family practitioner but is also seeing an endocrinologist. The documentation from the family practitioner does not support the level of diabetic testing, but medical records from the endocrinologist do support the level of testing.   2. Reviewers have the discretion to use claims history information to document an event, such as a surgical procedure, that supports the need for a service or item billed in limited circumstances. In some cases, this event occurs a number of years prior to the date of service on the claim being reviewed, making it difficult to collect medical record documentation. If repeated attempts to collect medical record of the event are unsuccessful, contractors have the discretion to consider claims history information as documentation of the event. Contractors shall document their  repeated attempts to collect the medical record if they chose to consider claims history information as documentation of the event. Example: A beneficiary is eligible for immunosuppressant drugs only if they received an organ transplant. Patients generall y remain on these life -saving drugs for the rest of their life so it is possible for the transplant to have occurred many years prior to the date of service being reviewed. If there was no record of the transplant in the medical documentation provided by t he ordering physician, the contractor may use claims history to validate the transplant occurred.   3. Reviewers shall use claims history information to verify that the frequency or quantity of supplies provided to a beneficiary do not exceed policy guidel ines.
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3. Reviewers shall use claims history information to verify that the frequency or quantity of supplies provided to a beneficiary do not exceed policy guidel ines.   4. Reviewers shall use claims history information to identify duplication and overutilization of services.  3.2.5 - Targeted Probe and Educate (TPE)  (Rev. 10132; Issued: 05- 15-2020; Effective: 06- 16-2020; Implementation: 06- 16-2020)   This section applies to MACs.   A. Overview   The purpose of Targeted Probe and Educate (TPE) is to decrease provider burden, reduce appeals, and improve the medical review/education process.   This section describes requirements that MACs shall follow when perfor ming medical review as part of TPE.   TPE reviews can be either prepayment or postpayment and involve MACs focusing on specific providers/suppliers that bill a particular item or service.   A round of TPE typically involves the review of 20- 40 claims, per pr ovider/supplier, per service/item, and corresponding education. In rare circumstances, CMS may approve a probe sample of other than 20- 40 claims. This process is typically repeated for up to three rounds, but may involve additional rounds at CMS direction. MACs discontinue the process if/when providers/suppliers become compliant. Providers/suppliers who remain non-compliant after three rounds of TPE are referred to CMS for further action.  B. Provider Selection   The MACs shall initiate a provider -specific, prepayment or postpayment review based upon data analysis, as discussed in 3.2.1. MACs shall also initiate targeted, provider-specific, prepayment or postpayment review upon referral from the Recovery Auditor Contractor (RAC), Comprehensive Error Rate Testing (CERT), Unified Program Integrity Contractor (UPIC), Office of Inspector General (OIG), or Government Accountability Office (GAO) when directed by CMS. MACs shall target providers/suppliers who have historically high claim denial rates, who have billing practices that vary from their peers, or when evidence suggests that there is a potential risk to the Medicare Trust Fund.  Probe Selection   The MACs shall select probe samples of typically 20-40 claims. Probe samples of different sizes may be deemed appropriate on a case-by-case basis, with approval by CMS.   Provider Notification Letter
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The MACs shall select probe samples of typically 20-40 claims. Probe samples of different sizes may be deemed appropriate on a case-by-case basis, with approval by CMS.   Provider Notification Letter   The MACs shall send a notification letter to providers/suppliers being targeted for review that:  Outlines the targeted probe & educate process,  Explains the process by which providers/suppliers will be able to receive one-on-one education and the types of education that will be available,  Notifies providers/suppliers that MACs shall have the option to refer providers/suppliers to the RAC or UPIC as a result of non-response to Additional Development Requests (ADRs), and  Includes the following language to remind providers of 42 CFR 424.535  In addition, we remind you that the regulation at 42 CFR 424.535 authorizes us to revoke Medicare billing privileges under certain conditions. In particular, we note that per 42 CFR 424.535(a)(8)(ii), CMS has the authority to revoke a currently enrolled provider or suppliers Medicare billing privileges if CMS determines that the provider or supplier has a pattern or pr actice of submitting claims that fail to meet Medicare requirements. C. TPE One -On-One Education   For the TPE process, one-on- one education is defined as teleconference calls, face- to-face visits, electronic visits using webinar technology, or other simil ar technologies that enable direct communication between the MAC educator and the provider/supplier. MACs shall record these activities in monthly reporting to CMS as well as document and maintain the results of the education, and/or attempts for education, for data analysis and possible future reporting.  Intra -Probe Education  The MAC may identify errors in the claim(s) that can be easily resolved during the course of providers/suppliers probe reviews. Easily curable errors include, but are not limited to, missing documentation that can be resolved through the submission of additional documentation and missing signatures that can be resolved with a signature attestation. When the MAC identifies an easily curable error, the MAC shall contact the provider to address the error and allow the provider to submit missing documentation, etc.  Post-Probe Education
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Post-Probe Education  The MAC shall contact the provider/supplier via telephone (or face- to-face, electronic visits using webinar technology, or other similar technologies a s they become available) to offer a one -on-one educational session after each round of probe review. If the provider/supplier declines the offer for one-on-one education, MACs shall maintain a record of the effort and the reason for denial. The purpose of this one-on-one education is to:  1) Alert the provider of errors identified and how they may be resolved for future claim submissions; and  2) Provide education regarding the review topic to help prevent new issues from arising during future rounds of review. This post-probe one-on- one education should be individualized, claims-specific, and conducted in a format that is interactive, allowing the provider/supplier to ask questions as needed.  The MAC shall provide a minimum of 45 days after each post-probe educational session, before selecting new claims for review, to allow time for the provider/supplier to cure identified errors.   D. Post- Probe Activity   Final Results Letter
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D. Post- Probe Activity   Final Results Letter   The MAC shall send the provider/supplier a letter detailing the results of the claims reviewed at the conclusion of each round of review. The MAC shall include details regarding the providers/suppliers specific claim errors. For providers/suppliers who will be released from review due to meeting the established error rate goal, res ults letters shall indicate that the provider is being released from review for one year, with the caveat that additional review may occur at any time should the MAC identified changes in billing pattern. For providers/suppliers who continue to have high e rror rates after three rounds of TPE review, results letters shall indicate that they have not met the established goal error rate and will be referred to CMS for additional action, which may include additional rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. Additionally, the letter shall include the following language to remind providers of 42 CFR 424.535.  In addition, we remind you that the regulation at 42 CFR 424.535 authorizes us to revoke Medicare billing privileges under certain conditions. In particular, we note that per 42 CFR 424.535(a)(8)(ii), CMS has the authority to revoke a currently enrolled provider or suppliers Medicare billing privileges if CMS determi nes that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements.   Determining the Need for Additional TPE  The MAC shall calculate the provider/supplier claim error rate and payment error rate at the conclusion of each round of TPE. The MAC shall use the provider/supplier error rate to determine whether an additional round of TPE is appropriate.  Closure and Monitoring  A provider/supplier may be removed from TPE after any round if they demonstrate l ow error rates or sufficient improvement in error rates, as determined by the MAC. MACs shall use data analysis to monitor the providers/suppliers who have been discontinued from the TPE process. MACs shall conduct follow-up review in one year or sooner if data analysis indicates changes in billing patterns or when potential risk to the Medicare Trust Fund is identified.  E. Referrals
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If a provider/supplier continues to have a high error rate at the conclusion of three rounds of TPE, the MAC shall refer to  CMS for further action. Referrals shall include details regarding the reason the provider/supplier was selected for TPE review, TPE review results, results of appealed denials (to the extent available at the time of referral), any education provided (or offered and refused), and any other relevant information that may be helpful in determining appropriate next steps.  The MAC shall refer suspected fraudulent providers to the UPIC at any time during the TPE process.   F. Next Steps   Once the MAC refers a pro vider/supplier to CMS, details are reviewed to determine if additional action must be taken by the MAC. Additional actions that may be required include, but are not limited to, additional rounds of TPE review, 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. If CMS directs the MAC to conduct an additional round of TPE review, the MAC shall send the provider/supplier a notification letter indicating that an additional round of review is required.  These reviews shall be of claims with dates of service at least 45 days after the prior rounds post probe education and after the provider/supplier has received the aforementioned notification letter.   3.3  Policies and Guidelines Applied During Review  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, CERT, Recovery Auditors, Supplemental Medical Review Contractors (SMRCs) and UPICs, as indicated.   A. Statutes, Regulations, the CMS Rulings, National Coverage Determinations, Coverage Provisions in Interpretive Medicare Manuals, and Local Coverage Determinations   The primary authority for all coverage provisions and subsequent policies is the Social Security Act. In general, MACs, CERT, Recovery Audit ors, SMRCs, and UPICs shall apply the provisions of the Act according to the following hierarchy of documents in effect at the time the item(s) or service(s) was provided to make medical review decisions:
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Social Security Act  Code of  Federal Regulations C MS Rulings  National Coverage Determination (NCDs)  Coverage provisions in Interpretive Manuals or Internet Only Manuals (IOM) which includes Medical Review Guidance in the Medicare Program Integrity Manual  CMS coding policies  Technical Direction Letters (TDLs)* The relevant MACs Local  Coverage Determination (LCDs) The relevant MACs local  articles  AHA Coding Clinics.  *TDLs that contain MR guidance may provide an exception to this hierarchy.   B. Coding  Guidelines   The MACs, CERT,  Recovery Auditors, and UPICs shall apply coding guidelines to services selected for review. All contractors shall determine that an item/service is correctly coded when it meets all the coding guidelines listed in the Current Procedural Terminology- 4 (CPT ) book, International Classification of Diseases Guidelines (ICD), CMS HCPCS or ICD policy or guideline requirements, LCDs, or MAC articles.  C. Internal Medical Review Guidelines   The MAC, CERT, Recovery Auditor, and UPIC staffs have the discretion to develop detailed written review guidelines to guide staff during claim reviews. Internal MR guidelines shall specify the information to be reviewed by reviewers and the appropriate resulting determination. Recovery Auditors are required to develop written review  guidelines in accordance with their SOW. The MACs, CERT, Recovery Auditors, and UPICs shall make their internal MR guidelines available to their staff, as needed. Internal MR Guidelines shall not create or change the CMS policy.  3.3.1 - Types of Review: Medical Record Review, Non -Medical Record Review, and Automated Review  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, SMRC, and UPICs, as indicated.  A. General   Most o f the claim review activities completed for the purpose of identifying inappropriate billing and avoiding improper payments are divided into three distinct types: Medical Record Review, Non- Medical Record Review, and Automated Review.   The chart below indicates which contractors perform which types of review:  Prepayment  Postpayment   Medical  Non-  Medical  Non- Contractor  Record  Medical  Automated  Record  Medical  Type  Review  Record  Reviews  Review  Record    Review    review  MACs  Yes Yes Yes Yes Yes CERT  No No No Yes No RACs  No No No Yes No SMRC  No No No Yes Yes UPIC  Yes No No Yes Yes
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Review    review  MACs  Yes Yes Yes Yes Yes CERT  No No No Yes No RACs  No No No Yes No SMRC  No No No Yes Yes UPIC  Yes No No Yes Yes   3.3.1.1 - Medical Record Review  (Rev. 11529; Issued: 07-28-2022; Effective: 08- 30-2022; Implementation: 08-30-2022)  This section applies to MACs, CERT, RACs, Supplemental Medical Review Contractor(s) and UPICs, as indicated.  A. Definition   Medical record review involves requesting, receiving, and reviewing medical documentation associated with a claim.   Medical record review, for the purpose of determining medica l necessity, requires a licensed medical professional to use clinical review judgment to evaluate medical record documentation.  B. Clinical Review Judgment   Clinical review judgment involves two steps:   1. The synthesis of all submitted medical record information (e.g. progress notes, diagnostic findings, medications, nursing notes, etc.) to create a longitudinal clinical picture of the patient; and  2. The application of this clinical picture to the review criteria is to make a reviewer determination on whether the clinical requirements in the relevant policy have been met. MAC, CERT, RAC, and UPIC clinical review staff shall use clinical review judgment when making medical record review determinations about a  claim.   Clinical review judg ment does not replace poor or inadequate medical records. Clinical review judgment by definition is not a process that MACs, CERT, RACs and UPICs can use to override, supersede or disregard a policy requirement. Policies include laws, regulations, the CMS  rulings, manual instructions, MAC policy articles attached to an LCD or listed in the Medicare Coverage Database, national coverage decisions, and local coverage determinations.  C. Credentials of Reviewers   The MACs, MRAC, and CERT shall ensure that medical  record reviews for the purpose of making coverage determinations are performed by licensed nurses (RNs), therapists or physicians. Current LPNs may be grandfathered in and can continue to perform medical record review. The MACs, MRAC, and CERT shall not hire any new LPNs to perform medical record review. UPICs, RACs and the SMRC shall ensure that the credentials of their reviewers are consistent with the requirements in their respective SOWs.
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During a medical record review, nurse and physician reviewers m ay call upon other health care professionals (e.g., dieticians or physician specialists) for advice. The  MACs, MRAC, and CERT, shall ensure that services reviewed by other licensed health care professionals are within their scope of practice and that their  MR strategy supports the need for their specialized expertise in the adjudication of particular claim type (i.e., speech therapy claim, physical therapy). RACs and the SMRC shall follow guidance related to calling upon other healthcare professionals as outlined in their respective SOWs.   RACs shall ensure that a licensed medical professional will perform medical record reviews for the purpose of determining medical necessity, using their clinical review judgment to evaluate medical record documentation. Ce rtified coders will perform coding determinations. CERT and MACs are encouraged to make coding determinations by using certified coders. UPICs have the discretion to make coding determinations using certified coders.   D. Credential  Files   The MACs, MRAC, CERT, RACs, and UPICs shall maintain a credentials file for each reviewer (including consultants, contract staff, subcontractors, and temporary staff) who performs medical record reviews. The credentials file shall contain at least a copy of the reviewers  active professional license.   E. Quality Improvement (QI) Process   The MACs, CERT, RACs, and SMRCs shall establish a Quality Improvement (QI) process that verifies the accuracy of MR decisions made by licensed health care professionals. The MACs, CERT, RACs, and SMRCs shall attend the annual medical review training conference as directed by the CMS and/or their SOW. The MACs, CERT, RACs, and SMRCs shall include inter -rater reliability assessments in their QI process and shall report these results as directed by CMS.   F. Advanced Beneficiary Notice (ABN)
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F. Advanced Beneficiary Notice (ABN)   The MACs, CERT, RACs, UPICs, and SMRCs shall request as part of the ADR, during a medical record review, a copy of any mandatory ABNs, as defined in Pub. 100-  04, Medicare Claims Processing Manual Chapter 30 sect ion 50.3.1. If the claim is determined not to be reasonable and necessary, the contractor will perform a face validity assessment of the ABN in accordance with the instructions stated in Pub. 100- 04 Medicare Claims Processing Manual chapter 30 section 50.6.3.  The Face Validity assessments do not include contacting beneficiaries or providers to ensure the accuracy or authenticity of the information. Face Validity assessments will assist in ensuring that liability is assigned in accordance with the Limitatio ns of Liability Provisions of section 1879 of the Social Security Act.  G. MAC Funding Issues   The MAC -medical record review work performed by medical review staff for purposes other than MR (e.g., appeals) shall be charged, for expenditure reporting purposes, to the area requiring medical review services.   All medical record review work performed by MACs shall:    Involve activities defined under the Medicare Integrity Program (MIP) at Section 1893(b)(1) of the  Act;  Be articulated in its medical review strategy;  and  Be designed in such a way as to reduce its Comprehensive Error Rate Testing (CERT) error rate or prevent the contractors error rate from  increasing.   The MACs shall be mindful that edits suspending a claim for medical review to check for issues other than inappropriate billing (i.e. completeness of claims, conditions of participation, quality of care) are not medical review edits as defined under Section 1893(b)(1) of the Act and cannot be funded by MIP. Therefore, edits resulting in work other than that defined in Section1893 (b) (1) shall be charged to the appropriate Program Management activity cost center. Activities associated with claims processing edits shall not be charged to MIP.  H. Review Timeliness Requirements   Prepayment Review Requirements for MACs