Review Determination Documentation Requirements

3.6.6 - Review Determination Documentation Requirements (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) This section applies to MACs, CERT, Recovery Auditors, and UPICs, as indicated. For each claim denied, in full or in part, the MACs, CERT, and UPICs shall carefully document the basis for the denial in the internal claim record. If there are several reasons for denial they shall document each reason in the internal claim record. In addition, the internal claim record should document the date and content of the provider notice of review (§ 3.2.2), additional documentation requests (§3.2.3), and third party documentation requests and response (§3.2.3.3). In verifying an overpayment, MACs, CERT, Recovery Auditors, and UPICs shall carefully document claims for services not furnished or not furnished as billed so that the denials are more likely to be sustained upon appeal and judicial review.