Medicare Claim Review Services
The Centers for Medicare & Medicaid Services (CMS) employs several strategies to ensure that payments to providers are appropriate and cover only those services that are medically necessary. One such way the Medicare Trust Fund is protected is through an active claim review program. While Beneficiary and Family Centered Care - Quality Improvement Organizations (BFCC-QIOs) like Livanta routinely provide case review services on behalf of Medicare beneficiaries, claim review services are additional activities provided by Livanta and funded by the Centers for Medicare & Medicaid Services (CMS). Claim review services represent an important activity of advancing Medicare's triple aim of better health, better care, and lower costs.
Medicare's claim review program includes activities that evaluate two main types of claims paid under Medicare Part A with high potential for errors: hospital inpatient admissions of short duration and claims in which hospitals paid under PPS re-submitted inpatient claims for a higher payment than what they had billed initially. In the coming weeks, Livanta will begin conducting this work in all states, territories, and Washington, D.C. As part of the review activities, Livanta's reviewers will evaluate whether the services performed were medically necessary and paid appropriately.
Updates
November 01, 2021
Livanta samples claims for review on a monthly basis for both HWDRG and SSR. For sampled claims, Livanta requests the corresponding medical records and completes the reviews. The weeks that Livanta plans to request medical records for sampled claims through 2022 are posted under the respective Review Type (HWDRG and SSR).
October 14, 2021
HWDRG requests for medical records will be sent to hospitals the week of 10/18/21 via fax where possible. If fax information for the medical record point of contact is not available, the medical record requests will be mailed via USPS to the medical record point of contact submitted on the MOA. If a hospital MOA has not been submitted with appropriate points of contact, then Livanta uses the medical record point of content entered in the CMS Program Resource System (PRS) for sending the medical records requests.
September 30, 2021
SSR requests for medical records will be sent to hospitals the week of 10/04/21 via fax where possible. If fax information for the medical record point of contact is not available, the medical record requests will be mailed via USPS to the medical record point of contact submitted on the MOA. If a hospital MOA has not been submitted with appropriate points of contact, then Livanta uses the medical record point of content entered in the CMS Program Resource System (PRS) for sending the medical records requests.
September 17, 2021
HWDRG requests for medical records will be sent to hospitals the week of 09/20/21 via fax where possible. If fax information for the medical record point of contact is not available, the medical record requests will be mailed via USPS to the medical record point of contact submitted on the MOA. If a hospital MOA has not been submitted with appropriate points of contact, then Livanta uses the medical record point of content entered in the CMS Program Resource System (PRS) for sending the medical records requests.
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