Supplemental Medical Review Contractor’s Role

1.4.1-Supplemental Medical Review Contractor’s Role The SMRC will perform research and analysis, MR, statistical sampling, and extrapolation. The SMRC will specifically include the following activities: • Perform Medicare Part A and Part B (including DME) post payment MR in accordance with CMS instructions including expedited reviews. The list of providers will be sent via secure email provided in Section 4.3; • For post payment medical review, develop and send a letter for the solicitation of medical records and supporting documentation needed to support the claims, when necessary; • Perform claim re-reviews for claims reviewed initially by the SMRC; • Perform statistical sampling and extrapolation to assess overpayment or potential overpayment(s) made on claims; • Access the Recovery Auditor Data Warehouse (RDW) prior to selecting claims for review to ensure they are not excluded or suppressed; • Upload all claim samples identified into the RDW; • Review all services in accordance with the applicable statutes, CMS guidelines, and coverage requirements; • Recommend claim denial for any claim when a provider fails to send medical records or supporting documentation; • Maintain a tracking system to reflect and identify MR activities for all claims; • Ensure coordination of efforts and prevent duplication of activities or interference with an existing investigation or corrective action plan; • Ensure each MR is conducted by a Registered Nurse (RN); • Ensure each coding review is conducted by a Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) with an active certification; • Ensure records are maintained confidentially in accordance with the Statement of Work (SOW) and applicable regulations; • Participate in Administrative Law Judge (ALJ) hearings as a participant or party, as appropriate, to defend positions or provide testimony; • Provide education on eligible claims to providers as requested for those claims reviewed by SMRC; and • Participate in discussion periods with providers as requested for those claims reviewed by SMRC that are eligible for Discussion & Education (D&E). The SMRC does not have responsibility for: • Claims processing and adjudication activities; • Performing redeterminations related to appealed initial determinations conducted by the SMRC; and • Cost report audit activities.