CAFM II Reporting for MR Activities

11.1.3 – CAFM II Reporting for MR Activities (Rev. 174, Issued: 11-17-06; Effective: 10-01-2006; Implementation: 10-02-06) Contractors shall report all costs associated with the medical review of claims, e.g., sampling design and execution; claims examination, reviewing medical records and associated documentation; assessing overpayments; and contacting providers to notify them of overpayment assessment decisions. All costs associated with collecting the overpayment shall be allocated to the appropriate overpayment collection CAFM II activity code. To be counted as medical review workload, all claims reviewed by medical review shall be identified in the MR strategy and be the result of a MR edit. If resources allow, a MR clinician may be shared with another functional area, such as provider outreach and education, claims processing or appeals, as long as only the percentage of the clinician’s time spent on MR activities is identified in the strategy and accounted for in the appropriate functional budget area. The review of a claim for MR purposes is only counted as medically reviewed once no matter how many times the same claim is reviewed during claims processing. MCS users will be exempt from this requirement until July 5, 2005. Effective July 5, 2005 the MCS system shall be revised to automatically deny duplicates of denied lines. Duplicates of denied lines are defined as newly submitted lines that duplicate a line that a contractor has (a) already denied, (b) medically reviewed, or (c) for which the contractor requested but did not received documentation. Denial of duplicate lines shall not be appealable unless the provider documents that the service was not a duplicate because it was performed more often than indicated in the original line. Use a “Duplicate non-paid” denial message whenever this denial is made.