MR Overview

11.1.1 – MR Overview (Rev. 174, Issued: 11-17-06; Effective: 10-01-2006; Implementation: 10-02-06) This chapter of the PIM lists the requirements contractors must follow when allocating MR Costs, Savings and Workload to the MR activities in CAFM and CROWD. These requirements formerly appeared in MCM, Part 1, 4213; MIM, Part 1, 1213 and the MR Budget and Performance Requirements (BPRs). Contractors must allocate to the MR activity code in CAFM II only the workload and costs associated with MR tasks. Contractors must allocate to the MR line in CROWD only these savings that are generated by MR tasks. For example: • If a nurse reviewer spends 90% of her time performing prepay complex medical review and 10% of her time performing appeals review at the request of the appeals unit, the contractor must allocate 90% of this nurse's salary/fringes to 21221 and the 10% to the appropriate appeals activity code. • If a non-clinician medical reviewer spends 80% of his time performing Routine review and 20% of his time performing suspect duplicate reviews, the contractor must allocate 80% of this reviewer's salary/fringes to 21002 and the 20% to the appropriate claims processing activity code. • If a nurse reviewer spends 70% of her time performing postpay complex review for the purpose of making a coverage determination on a provider who has been selected for targeted PCA review and 30% of her time performing reviews to support the claims processing unit, the contractor should report 70% to Postpay Complex Review 21222 and 30% to the appropriate claims processing activity code. Refer to chapter 1, section 2 www.cms.gov/manuals/108_pim/pim83c01.asp#Sect2 of this manual for detailed overview of the MR Program. This chapter lists the requirements contractors must follow when allocating MR costs and workload to the MR activities in CAFM II. Contractors will be given a specified maximum budget for MR. Based on this budget the contractor is asked to develop a unique MR strategy within their jurisdiction that is consistent with the goal of reducing the error rate. The contractor shall utilize their targeted budget in its entirety on MR activities toward the prevention of waste and abuse to the Medicare program.