CMS prohibits contractors from adding new denial reasons on first and second level of appeals 9/15/2015

CMS issued MLN Matters SE1521 limited the scope of review on redeterminations and reconsideratons of certain claims. This impacts claims from physicians, providers including home health & hospice, and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare Beneficiaries.  It has be published by CMS to inform providers of the clarification CMS has given to MACs and Qualified Independent Contractors (QICs) regarding scope of review for redeterminations (Techmical Direction Letter-15407).  This updated instructions applies to redetermination request received by a MAC or QIC on or after August 1, 2015 and will not be applied retroactively.

For redeterminations and reconsiderations of claims denied following a post-payment review or audit, CMS has instructed MACs and QICs to limited their review to the reason(s) the claim or line item at issued was initially denied.  This means they cannot add additional reasons for denial of claims after the initial denial.  This probably means the denial will now include more reasons for the denial, but it appears to be a step in the right direction.

Link:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1521.pdf