CMS Manual System

1 CMS Manual System Department of Health & Human Services (DHHS) Pub. 100-08 Medicare Program Integrity Centers for Medicare & Medicaid Services (CMS) Transmittal 59 Date: NOVEMBER 28, 2003 CHANGE REQUEST 2937 I. SUMMARY OF CHANGES: NEW/REVISED MATERIAL - EFFECTIVE DATE: 1/1/2004 *IMPLEMENTATION DATE: 1/5/2004 Disclaimer: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. II. SCHEDULE OF CHANGES (R = REVISED, N = NEW, D = DELETED) R/N/D CHAPTER/SECTION/SUBSECTION/TITLE N 3/ Documentation Specifications for Areas Selected for Prepayment or Postpayment MR R 5 Written Orders III. FUNDING: *Medicare contractors only: These instructions should be implemented within your current operating budget. IV. ATTACHMENTS: X Business Requirements X Manual Instruction Confidential Requirements One-Time Notification Business Requirements Pub.

2 100-8 Transmittal: 59 Date: November 28, 2003 Change Request 2937 I. GENERAL INFORMATION A. Background: N/A B. Policy: N/A C. Provider Education: Contractors shall inform affected provider communities by posting either a summary or relevant portions of this instruction on their websites within two weeks of the issuance date of this instruction. In addition, this same information shall be published in your next regularly scheduled bulletin. If you have a listserv that targets the affected provider communities, you must use it to notify subscribers that information about signature requirements is available on your Web Site. II. BUSINESS REQUIREMENTS Shall" denotes a mandatory requirement "Should" denotes an optional requirement Requirement # Requirements Responsibility The contractor shall not deny claims on the basis of type of signature type submitted, with an exception for Durable Medical Equipment Certificates of Medical Necessity.

3 Contractor II. SUPPORTING INFORMATION AND POSSIBLE DESIGN CONSIDERATIONS A. Other Instructions: N/A X-Ref Requirement # Instructions B. Design Considerations: N/A X-Ref Requirement # Recommendation for Medicare System Requirements C. Interfaces: N/A D. Contractor Financial Reporting /Workload Impact: N/A E. Dependencies: N/A F. Testing Considerations: IV. OTHER CHANGES Citation Change N/A V. SCHEDULE, CONTACTS, AND FUNDING Effective Date: 1/1/2004 Implementation Date: 1/5/2004 Pre-Implementation Contact(s): Dan Schwartz Post-Implementation Contact(s): Regional Offices These instructions should be implemented within your current operating budget Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions Table of Contents (Rev.)

4 59, 11-28-03) 1 Introduction Provider Tracking System (PTS) Evaluating Effectiveness of Corrective Actions 2 Verifying Potential Error and Setting Priorities Determining Whether the Problem is Widespread or Provider Specific - Administrative Relief from Medical Review and Benefit Integrity in the Presence of a Disaster 3 Provider Education Provider Contacts By the BI Unit Article 4 -- Overview of Prepayment and Postpayment Review for MR Purposes Determinations Made During Prepayment and Postpayment MR -- Documentation Specifications for Areas Selected for Prepayment or Postpayment MR Additional Documentation Requests (ADR) During Prepayment or Postpayment MR Completing Complex Reviews Handling Late Documentation Denials Documenting That A Claim Should Be Denied Internal MR Guidelines Types of Prepayment and Postpayment Review - Spreading Workload Evenly - New Provider / New Benefit Monitoring - Review That Involves Utilization Parameters 5 Prepayment Review of Claims For MR Purposes Automated Prepayment Review Prepayment Edits Categories of MR Edits CMS Mandated Edits 6 Postpayment Review of Claims For MR Purposes Postpayment Review Case Selection Location of Postpayment Reviews Re-adjudication of Claims Calculation of the Correct payment Amount and Correct Subsequent Over/Underpayment Notification of Provider(s)

5 And Beneficiaries of the Postpayment Review Results Provider(s) Rebuttal(s) of Findings Recovery of Overpayments Evaluation of the Effectiveness of Postpayment Review and Next Steps Postpayment Files Reversed Denials Pending Further Action by Law Enforcement 8 Overpayment Procedures Overpayment Assessment Procedures Definition of Overpayment Assessment Terms Assessing Overpayment When Review Was Based on SVRS Assessing Overpayment or Potential Overpayment When Review Was Based on Limited Sample or Limited SVRS Sub sample Contractor Activities to Support Assessing Overpayment Conduct of Expanded Review Based on SVRS and Recoupment of Projected Overpayment by Contractors Consent Settlement Offer Based on Potential Projected Overpayment - Consent Settlement Budget and Performance Requirements (BPR)

6 Voluntary Repayment During an Active Fraud Investigation - Procedures for the Benefit Integrity (BI) and Medical Review (MR) Units on Unsolicited/Voluntary Refund Checks Coordination with Aduit and Reimbursement Staff 9 Suspension of Payment When Suspension of Payment May Be Used Fraud or Willful Misrepresentation Exists Fraud Suspensions Overpayment Exists But the Amount is Not Determined General Suspensions Payments to be Made May Not be Correct General Suspensions Provider Fails to Furnish Records and Other Requested Information General Suspensions Procedures for Implementing Suspension of Payment CMS Approval The Notice of Intent to Suspend Prior Notice Versus Concurrent Notice Content of Notice Shortening the Notice Period for Cause Mailing the Notice to the Provider Opportunity for Rebuttal Claims Review and Case Development During the Suspension Period Claims

7 Review Case Development Duration of Suspension of Payment Removing the Suspension Disposition of the Suspension Contractor Suspects Additional Improper Claims Suspension Process for Multi Region Issues DMERCs Other Multi Regional Contractors 10 Referral of Cases to Other Entities for Action Referral of Cases to OIG/OI Referral of Potential Fraud Cases Involving Railroad Retirement Beneficiaries Cases Requiring Immediate Referral to OIG/OI Contractor Actions When Cases Are Referred to and Accepted by OIG/OI Suspension Denial of Payments for Cases Referred to and Accepted by OIG/OI Recoupment of Overpayments OIG/OI Case Summary and Referral Actions to be Taken When A Fraud Case is Refused by OIG/OI Continue to Monitor Provider and Document Case File Take Administrative Action on Cases Referred to and Refused by OIG/OI Refer to Other Law Enforcement Agencies Referral to State Agencies or Other Organizations Referral to PROs 11 Administrative Sanctions The Contractor s Role Authority to Exclude Practitioners, Providers, and Suppliers of Services Basis for Exclusion Under 1128(b)(6)

8 Of the Act Identification of Potential Exclusion Cases Development of Potential Exclusion Cases Contents of Sanction Recommendation Notice of Administrative Sanction Action Notification to Other Agencies Denial of Payment to an Excluded Party Denial of Payment to Employer of Excluded Physician Denial of Payment to Beneficiaries and Others Appeals Process Reinstatements Monthly Notification of Sanction Actions 12 Civil Monetary Penalties Law (CMPL) Background Basis of Authority Purpose Enforcement Administrative Actions Documents CMP Authorities CMPs Delegated to CMS CMPs Delegated to OIG Referral Process Referral Process to CMS Referrals to OIG CMS Generic CMP Case Contents Additional Guidance for Specific CMPs Beneficiary Right to Itemized Statement Medicare Limiting Charge Violations 13 Monitor Compliance Resumption of Payment to A Provider Continued Surveillance After Detection of Fraud -- Documentation Specifications for Areas Selected for Prepayment or Postpayment MR (Rev.)

9 59, 11-28-03) The contractor may use any information they deem necessary to make a prepayment or postpayment claim review determination. This includes reviewing any documentation submitted with the claim as well as soliciting documentation from the provider or other entity when the contractor deems it necessary and in accordance with PIM Chapter 3, Section A -- Review of Documentation Submitted with the Claim If a claim targeted for prepayment or postpayment review (including automated, routine, or complex) contains a modifier indicating that additional documentation is attached or was submitted simultaneously with an electronic claim, the contractor must review the documentation before denying the claim. There are two exceptions to this rule. Contractors may deny without reviewing attached or simultaneously submitted documentation (1) when clear policy serves as the basis for denial, and (2) in instances of medical impossibility (see PIM Chapter 3, ).

10 NOTE: The term "clear policy" means a statute, regulation, NCD, coverage provision in an interpretive Manual , or LMRP specifies the circumstances under which a service will always be considered non-covered or incorrectly coded. Clear policy that will be used as the basis for frequency denials must contain utilization guidelines that the contractor considers acceptable for coverage. B -- Signature Requirements Medicare requires a legible identity for services provided/ordered. The method used ( hand written, electronic, or signature stamp) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. Rather, an indication of a signature in some form needs to be present. Do not deny a claim on the sole basis of type of signature submitted. Providers using alternative signature methods ( a signature stamp) should recognize that there is a potential for misuse or abuse with a signature stamp or other alternate signature methods.