Industry Insights

CMS Clarification Issued Regarding Medical Review Scope

June 2016
Author:  Julie Bilyeu

Julie Bilyeu

Managing Director


Health Care

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


The Centers for Medicare & Medicaid Services (CMS) recently provided guidance limiting the scope of review for redeterminations and reconsiderations. A redetermination is the first level of appeal for a medically reviewed claim, while reconsideration is the second level of appeal.

The new guidance limits the Medicare Administrative Contractor (MAC) or Qualified Independent Contractor (QIC) review only to information related to the initial reasons for claim denial. Prior to the guidance, the reviewers could raise new issues at their discretion as long as the issues were relevant to the claim redetermination or reconsideration.

For claims initially denied because of the provider’s failure to submit documents or insufficient documentation, the MAC or QIC will fully review all items and services.

This guidance applies to all redetermination and reconsideration requests received by the MAC or QIC on or after April 18, 2016, and won’t be retroactively applied.

For more information, read the full CMS article or contact your BKD advisor.

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