Revised Limitations on the Scope of Review for Redeterminations & Reconsiderations


CMS LogoThe Center for Medicare and Medicaid Services (CMS) has recently issued a revised directive to its contractors handling appeals that are a result of a “complex prepayment reviews, complex postpayment reviews or automated post payment reviews”. CMS has informed the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Qualified Independent Contractor (QIC) that during the redetermination and reconsideration levels they may only “limit their review to the reason(s) the claim or line item at issue was initially denied”.

This means that the contractors may no longer deny your claim for a different reason upon further review of the claim, they may only review and make a decision based on the initial issue at hand. However, this limit doesn’t apply to appeals that are the result of an automated prepayment review denial. The limit on the scope of review only applies to appeals which are the result of denials due to complex prepayment reviews, complex post-payment reviews or automated post payment reviews.

This is a beneficial shift in policy. Previously, the DME MACs and the QIC could still ”develop new issues and evidence at their discretion” and issue unfavorable decisions for any reason besides the one provided with initial determination; even on post-payment reviews. Now, they may only “develop new issues and evidence at their discretion” when a claim is denied on an automated pre-payment review basis only.

This revised directive and instructions only applies to redetermination and reconsideration requests received by the DME MAC or QIC on or after April 18, 2016. The revised instructions will not be applied retroactively. You may view the MLN Matters article which outlines these new directives here.

Questions? Contact Joe McTernan at jmceterna@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org