Use of Claims History Information in Claim Payment Determinations
The ACs, MACs, CERT and RACs conduct complex medical review and make payment determinations on claims. This CR updates instructions on the use of claims history information during the course of medical review. All requirements in this Change Request (CR) are effective for CERT reviews retroactively for the November 2011 report period. All requirements for ACs, MACs and RACs are applicable for reviews conducted on or after 30 days after the issuance of this CR.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: February 25, 2011
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.