Use of Claims History Information in Claim Payment

3.2.4 - Use of Claims History Information in Claim Payment Determinations (Rev. 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) A. Contractors to Which This Section Applies This section applies to MACs, CERT, SMRC, UPIC, and RACs. B. General In certain circumstances it may be appropriate for medical reviewers to use relevant and accessible claims history to assist in making medical record review determinations. Examples of when this may be used for payment purposes, include, but are not limited to: 1. Reviewers have the discretion to use beneficiary payment history to identify other providers, other than the billing entity, who may have documentation to support payment of a claim. MAC, CERT, SMRC, and RAC reviewers have the discretion to contact identified providers for supporting documentation. Example: A diabetic beneficiary may have an order from a family practitioner but is also seeing an endocrinologist. The documentation from the family practitioner does not support the level of diabetic testing, but medical records from the endocrinologist do support the level of testing. 2. Reviewers have the discretion to use claims history information to document an event, such as a surgical procedure, that supports the need for a service or item billed in limited circumstances. In some cases, this event occurs a number of years prior to the date of service on the claim being reviewed, making it difficult to collect medical record documentation. If repeated attempts to collect medical record of the event are unsuccessful, contractors have the discretion to consider claims history information as documentation of the event. Contractors shall document their repeated attempts to collect the medical record if they chose to consider claims history information as documentation of the event. Example: A beneficiary is eligible for immunosuppressant drugs only if they received an organ transplant. Patients generally remain on these life-saving drugs for the rest of their life so it is possible for the transplant to have occurred many years prior to the date of service being reviewed. If there was no record of the transplant in the medical documentation provided by the ordering physician, the contractor may use claims history to validate the transplant occurred. 3. Reviewers shall use claims history information to verify that the frequency or quantity of supplies provided to a beneficiary do not exceed policy guidelines. 4. Reviewers shall use claims history information to identify duplication and overutilization of services.