Mandatory Policy Provisions

3.3.2.3 - Mandatory Policy Provisions (Rev. 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) This section applies to MACs, RACs, SMRC, CERT and UPICs, as indicated. CERT contractors select claims for review on a random basis and do not select claims that are suspect. The CERT reviewers shall review every line on the randomly selected claim that affects payment to determine if the following types of requirements are met: • Coding requirements; • Benefit category requirements; • The reasonable and necessary requirements of the NCDs and LCDs, among others. The MACs, RACs, SMRC, and UPICs select claims to prevent or identify an improper payment. They are only required to review the suspect line and not every line on the selected claims. Along with reviewing the line for coding accuracy, the MACs should review for medical necessity if the provider has been notified that both types of review will occur. The RACs shall review the claim line(s) identified, as per the CMS-approved review guidelines, as indicated to the provider in the ADR letter, and in accordance with their SOW. The UPICs shall use discretion in notifying the provider.