Industry Insights

CMS Tightens Deadlines for Review Contractors

November 2014
Author:  Sherri Robbins

Sherri Robbins

Senior Managing Consultant


Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)


On October 17, 2014, the Centers for Medicare & Medicaid Services (CMS) published Transmittal 547, which affects the amount of time review contractors have to complete complex medical reviews. Complex medical reviews are those that require information from providers for review contractors to make a determination. These changes will be implemented with dates of service beginning February 25, 2015, shortening the amount of time Medicare Administrative Contractors (MAC) have to complete complex reviews from 60 to 30 calendar days. This transmittal also details requirements for other medical review contractors including Recovery Audit Contractors (RAC), Zone Program Integrity Contractors (ZPIC), Certified Error Rate Testing (CERT) and Supplemental Medical Review Contractors (SMRC).

These changes are a positive step for providers; historically, it has taken more than 60 days for providers to receive a decision from review entities. The decreased time frame allowed for the review entities to make a determination only affects claims where additional documentation is requested, which may include physician evaluations, consultations, progress notes, hospital records and other documents needed to reach a conclusion. Other review deadlines outlined in this transmittal include:

  • Thirty days for MACs to make a determination for prepayment review and enter their decision in the Medicare system; this applies only to prepayment routine reviews, prepayment complex reviews and prepayment documentation compliance reviews—it does not include third-party liability claims, on which MACs have 60 days to make a determination
  • Thirty days for RACs to complete post-payment review and communicate results to the provider
  • Sixty days for ZPICs to complete prepayment review and notify the MAC

Post-payment review requirements for MACs did not change. MACs still need to make a determination and mail the review results notification letter to the provider within 60 days of receiving the additional documentation request (ADR), provided the documentation was received within 45 calendar days of the ADR date. 

MACs must adhere to state laws that require an evidentiary hearing for the beneficiary before any denials are processed. The MAC must review the claim within 30 days, allow the time required for the evidentiary hearing and continue with processing the claim on the next business day. MACs and RACs must count Day One as the date each new medical record is received in the mailroom, making it critical for providers to send requested documentation in a manner that allows tracking and/or return receipts. MACs and RACs also must give each new received medical record an independent 30-day review time period. 

In addition to the changes outlined above, CMS also published Transmittal 243, which sets the interest rate on overpayments and underpayments to Medicare providers at 10.75 percent, effective October 20, 2014. The Secretary of Treasury certifies the interest rate quarterly. This reflects the first-quarter notification for fiscal year 2015. 

For more information on these transmittals, refer to Publication 100-06, Medicare Financial Management Manual, and Publication 100-08, Medicare Program Integrity Manual. You also may contact your BKD advisor.

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