Conducting the Review

8.4.6.3 - Conducting the Review (Rev. 906; Issued: 09-26-19; Effective: 01-02-19; Implementation: 01-02-19) Following the contractor’s receipt of the requested documentation (or the end of the period to submit or make available the requested documentation, whichever comes first), the contractor shall start its review of the claims. The contractor may ask for additional documentation as necessary for an objective and thorough evaluation of the payments that have been made, but the contractor need not hold up conducting the review if the documents are not provided within a reasonable time frame. The contractor shall use physician consultants and other health professionals in the various specialties as necessary to review or approve decisions involving medical judgment. The review decision is made on the basis of Medicare law, CMS rulings, regulations, national coverage determinations, Medicare instructions, and regional/local contractor medical review policies that were in effect at the time the item(s) or service(s) was provided. The contractor shall document: (1) All findings made so that it is apparent from the contractor’s written documentation if the initial determination has been reversed, and (2) The amount of all overpayments and underpayments and how they were determined. The contractor is encouraged to complete its review and calculate the net overpayment within 90 calendar days of the start of the review (i.e., within 90 calendar days after the contractor has either received the requested documentation or the time to submit or make available the records has passed, whichever comes first). However, there may be extenuating circumstances or circumstances out of the contractor’s control where the contractor may not be able to complete the review within this time period (e.g., the contractor has made a fraud referral to the OIG and is awaiting the latter’s response before pursuing an overpayment). The contractor’s documentation of overpayment and underpayment determinations must be clear and concise. The contractor shall include copies of the local coverage determination and any applicable references needed to support individual case determinations. Compliance with these requirements facilitates adherence to the provider and supplier notification requirements.