Types of Claims for Which Contractors Are Responsible

1.3.5 - Types of Claims for Which Contractors Are Responsible (Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14) A. MACs The MACs should, at their discretion perform medical review functions for all claims appropriately submitted to them. Although they will continue to perform a number of quality functions, quality improvement organizations (QIOs) will no longer be performing the majority of utilization reviews for acute inpatient prospective payment system (IPPS) hospital and long-term care hospital (LTCH) claims. The review of acute IPPS hospital and LTCH claims (which, for the purposes of this section, also includes claims from any hospital that would be subject to the IPPS or LTCH PPS had it not been granted a waiver) is now the responsibility of the ACs and MACs. An exception occurs when a provider requests a higher-weighted diagnosis related group (DRG) review from the QIO. The QIO will continue to perform those reviews. QIOs will also continue to perform reviews related to quality of care and expedited determinations. The MACs shall include claims for which they are responsible when performing data analysis to plan their medical review strategy. Amendments to plans and strategies shall be made as needed if analysis indicates adjustment of priorities. B. CERT The CERT review contractor is responsible for reviewing claims randomly selected by the CERT statistical contractor. C. Recovery Auditors In general, Recovery Auditors are responsible for reviewing claims where improper payments have been made or there is a high probability that improper payments were made. D. SMRC Medical review will be performed on Part A, Part B, and DME providers and suppliers as directed by CMS.