Automated Review

3.3.1.3 - Automated Review (Rev. 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) A. Definition An automated review occurs when a claim determination is made at the system level without a human review of the medical record, using available electronic information. CERT refers to all reviews where no documentation was requested as “T-claim review.” T-claims are a particular category of claim reviewed by CERT. T-claims are claims that were automatically denied by the MAC. B. Basis for Automated Reviews Contractors shall ensure that automated denials are based on clear policy that serves as the basis for denial. The term “clear policy” means a statute, regulation, NCD, or LCD that specifies the circumstances under which a service will always be considered non- covered, incorrectly coded, or improperly billed. When a clear policy exists (or in the case of a Medically Unlikely Edit (MUE)), MACs have the discretion to automatically deny the services without stopping the claim for manual review, even if documentation is attached or simultaneously submitted. Reviewers shall still make a determination based on the liability limitations of §1879 of the Act. A MUE is a unit of service (UOS) edit for a Healthcare Common Procedure Coding system (HCPCS)/Current Procedural Terminology (CPT) code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum UOS that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. The MUE program provides a method to report medically reasonable and necessary UOS in excess of a MUE. An MUE is another example of an automated review that may be implemented by the review contractor, if permissible under their Statement of Work (SOW). Automated edits can be used for apparent typographical errors (e.g., 10,000 blood cultures for the same beneficiary on the same day). MACs shall implement automated prepayment review whenever appropriate.