Prepayment Review of Claims Involving Utilization Parameters

3.4.1.4 - Prepayment Review of Claims Involving Utilization Parameters (Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17) This section applies to MACs. A. For Non-lab Claims The MACs shall implement prepayment edits that will prevent payment to providers who have a pattern of billing for items or services that are not covered, incorrectly coded or inappropriately billed. The MACs shall respond quickly when they identify providers who seem to have egregious overutilization of a non-lab item or service and who bill for egregious amounts. The identification of, and response to these providers shall be within the context of the MAC’s MR Strategy and prioritization of review targets. B. Utilization Denials The MACs have the discretion to establish edits to automatically deny services when overutilization of a non-lab service is identified and clear policy serves as the basis for denial. The MACs shall establish medical record review edits and make individual claim determinations when overutilization of a non-lab service is identified and there is not clear policy to serve as the basis for denial. The MACs shall establish medical record review edits that do not involve utilization parameters and make individual claim determinations when overutilization of a lab service is identified and there is no clear policy to serve as the basis for denial. For example, if the problem is limited to a few laboratory providers, the MAC could develop a provider-specific prepayment edit to suspend payment for all of the lab services in question from the problem providers. If the problem is widespread, the MAC could develop a service-specific edit to suspend payment for all of the lab services in question or all of the services in question for a particular diagnosis or revenue code. Based on data analysis within each MAC jurisdiction, the MACs shall focus the edit by provider, diagnosis, procedure code, or in any other way except by use of a utilization parameter.