Prepayment Review Edits

3.4.1.5 - Prepayment Review Edits (Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11) This section applies to MACs. A. Automated Edits Automated prepayment edits, designed by MAC staff, are put in place to prevent payment for non-covered, incorrectly coded, or inappropriately billed services. Most automated payment edits will be service-specific. The MAC will rarely install a provider-specific automated prepayment edit. B. Limits on Automated Prepayment Review The MACs shall not install edits that result in the automatic denial of payment for items or services based solely on the diagnosis of a progressively debilitating disease when treatment may be reasonable and necessary. The appearance of a progressively debilitating disease on a claim or history does not permit automated denials that presume a stage of that disease that negates the effectiveness of treatment. Likewise, when a beneficiary with a progressively debilitating disease experiences an illness or injury unrelated to his or her progressively debilitating disease, the provider should submit a claim with a primary diagnosis that most accurately reflects the need for the provided item or service. For instance, a claim for treatment for an acute urinary tract infection cannot be denied by automatic edit just because the beneficiary has a diagnosis of multiple sclerosis.