Attachment to Letter for Provider Site Reviews - (Rev. 3, 11-22-00)

7.1 - Attachment to Letter for Provider Site Reviews - (Rev. 3, 11-22-00) Following is a list of the claims denied as a result of the review: • Beneficiary Name: John Smith • HI Claim Number: 000-00-0000 A • Service Dates: 12/08/97 - 12/08/97 • Services Denied and Dates: Magnetic Resonance Imaging (MRI) 12/08/97 • Reason for Denial: MRI's are not considered reasonable and medically necessary for the diagnosis of xxxx. • Why the Provider is Responsible: We believe you knew or should have known that the services were not reasonable and necessary because you were notified in a Provider Bulletin. The Bulletin dated April 1, 1997, outlined Local Medical Review Policy which indicated that MRI's were not covered for the diagnosis of xxxx. Therefore, you are responsible for paying the overpayment amount. • Overpayment: $900.00 • Beneficiary Name: Mary Smith • HI Claim Number: 000-00-0000B • Service Dates: 10/01/97 - 10/31/97 • Services Denied and Dates: Physical therapy evaluation and re-evaluation on 10/03/97 and 10/26/97. • Reason for Denial: The two physical therapy visits are not reasonable and medically necessary because the medical documentation shows that the patient was ambulatory and had no functional problems which would have required a physical therapy evaluation or re-evaluation. • Why you are Responsible: In a letter dated 07/30/97 you were notified that such therapy evaluation and re-evaluation were not considered reasonable and necessary. Therefore, you are responsible for the overpayment. • Overpayment: $ 200.00 • Beneficiary Name: Tom Jones • HI Claim Number: 000-00-0000A • Service Dates: 12/10/97 - 12/31/97 • Services Denied and Dates: 10 physical therapy visits from 12/10/97 - 12/31/97 • Reason for Denial: No plan of care signed by a physician. • Why you are responsible: We find you responsible for the overpayment because regulations at 42 CFR, and manual instructions at §xxxx, clearly require a plan of care signed by a physician for therapy visits. • Overpayment: $1,200.00