Purpose of the Supplemental Medical Review Contractor

1.1-Purpose of the Supplemental Medical Review Contractor The purpose of the SMRC is to perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the Medical Review (MR) functions primarily for Medicare Fee-for-Service (FFS); other product line analysis is limited and may include Medicaid FFS, private and group health insurance lines of business and Prescription Drug Plan (Part D). One of the primary tasks will be conducting large volumes of nationwide MR as directed by the Centers for Medicare & Medicaid Services (CMS). The MR will be performed on Medicare FFS claims for Part A, Part B, and DMEPOS programs. These medical review activities will assess compliance with Medicare’s coding, coverage, billing, and payment requirements and identify claims improperly paid. The SMRC will recommend recoupment and/or adjustment for claims identified as improperly paid. Having a centralized MR resource that can perform large volume of MR nationally shall allow for a timely and consistent execution of MR review, activities, and decisions. The SMRC shall select subject claims, perform research and/or data analysis, and conduct reviews in a manner that will minimize provider and supplier burden.