The MAC and SMRC Medical Review Program

1.3.7 - The MAC and SMRC Medical Review Program (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) The MR program is designed to prevent improper payments in the Medicare FFS program. Whenever possible, MACs are encouraged to automate this process; however it may require the evaluation of medical records and related documents to determine whether Medicare claims were billed in compliance with coverage, coding, payment, and billing policies. The statutory authority for the MR program includes the following sections of the Social Security Act (the Act): • Section 1833(e) which states, in part "...no payment shall be made to any provider... unless there has been furnished such information as may be necessary in order to determine the amounts due such provider ...;" • Section 1842(a)(2)(B) which requires ACs and MACs to "assist in the application of safeguards against unnecessary utilization of services furnished by providers ...; " • Section 1862(a)(1) which states no Medicare payment shall be made for expenses incurred for items or services that "are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member;" • The remainder of Section 1862(a) which describes all statutory exclusions from coverage; • Section 1893(b)(1) establishes the Medicare Integrity Program which allows contractors to review activities of providers of services or other individuals and entities furnishing items and services for which payment may be made under this title (including skilled nursing facilities and home health agencies), including medical and utilization review and fraud review (employing similar standards, processes, and technologies used by private health plans, including equipment and software technologies which surpass the capability of the equipment and technologies. . .” • Sections 1812, 1861, and 1832 which describe the Medicare benefit categories; and • Sections 1874, 1816, and 1842 which provide further authority. The regulatory authority for the MR program rests in: • 42 CFR 421.100 for intermediaries. • 42 CFR 421.200 for carriers. • 42 CFR 421.400 for MACs. The UPICs shall refer to chapter 4 for MR for BI purposes.