Manual Medical Review State Resources

The American Taxpayer Relief Act of 2012 (ATRA) was signed into law by President Obama on January 2, 2013. This law extends the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2013. Section 603 of this act contains a number of Medicare provisions affecting the outpatient therapy caps and manual medical review (MMR) threshold.

For manual medical review, Medicare Administrative Contractors (MACs) conducted prepayment review on claims reaching the $3,700 threshold with dates of service January 1, 2013, to March 31, 2013. CMS requested that MACs conduct these manual medical reviews within 10 days.

Effective April 1, 2013, the Recovery Auditor Contractors (RACs) conduct reviews for all claims processed on or after April 1, 2013. RACs will complete two types of review, prepayment review and postpayment review. View specific information and resources by clicking on each state.

Hawaii Washington, D.C. Maryland Delaware New Jersey Connecticut Rhode Island Massachusetts New Hampshire Vermont West Virginia Maine New York Pennsylvania Virginia North Carolina South Carolina Georgia Florida Alabama Ohio Michigan Indiana Kentucky Tennessee Mississippi Illinois Wisconsin Louisiana Arkansas Missouri Iowa Minnesota Texas Oklahoma Kansas Nebraska South Dakota North Dakota Alaska New Mexico Arizona Colorado Wyoming Montana Utah Idaho Nevada California Oregon Washington Puerto Rico Virgin Islands American Samoa Northern Mariana Islands Guam

Prepayment Review

The 11 states subject to prepayment review at $3,700 are Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina, and Missouri. Prepayment review occurs when services have been provided and claims are submitted but the claim is stopped for review before payment is made. When claims exceed $3,700 in these states, the MAC will send an additional documentation request to the provider, requesting that more documentation be sent to the RAC. The RAC, then, will conduct the prepayment review within 10 business days of receiving the additional documentation and will notify the MAC of the decision.

If a determination is made that services are covered, the provider will be paid after the review. If recovery auditors determine that claims should not be covered, a review results letter will be sent to the provider. That letter will clearly document the rationale of the determination. There is an opportunity to appeal if the provider disagrees with the determination.

Postpayment Review

Postpayment review occurs when services have been provided, a claim is submitted and has been adjudicated for payment, and the claim is paid. In states subject to postpayment review (all states except for the 11 prepayment review states), the MAC will flag claims that exceed $3,700, request additional documentation from the provider, and pay the claim. The MAC will send an additional document request to the provider immediately after payment, requesting that the additional documentation be sent to the RAC. The RAC will conduct the postpayment review and will notify the MAC of the decision.

According to CMS, RACs are encouraged to complete postpayment review in 10 business days. If the decision is that services should not be covered, a demand letter will be sent to the provider clearly documenting the rationale for the determination. The MAC will seek to recoup money for services deemed not reasonable and necessary.” The provider can pay back the funds by check, have the funds recouped from future payments, or appeal the decision.

Methods for Submission of Information

RACs will accept requested documentation from the provider by fax, regular, mail, CD/DVD, or electronically through the electronic submission of medical documentation system (esMD). If a provider knows a patient has exceeded $3,700 and wants to submit information with the claim instead of waiting for an ADR request, the provider can put “PWK” (for “paperwork”) on the claim form and attach the documentation. MACs offer additional information on their websites regarding use of PWK.

Each RAC has a portal on its website that providers can access to confirm that sent information has been received, and to check determination status.

Last Updated: 06/27/2013

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