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March 3, 2021

J15 Post Pay Resumptive Review Status Update 08/17/2020 – 12/31/2020

Beginning August 17, 2020, CMS directed the MACs to resume fee-for-service medical review activities beginning with post payment reviews of items/services provided before March 1, 2020. Items and services are selected based upon high error rates and/or potential overutilization identified through data analysis.

CGS Medical Review is dedicated to the integrity of the Medicare program. CGS welcomes provider inquiries and continues to offer education sessions to ensure providers understand CMS regulations with the goal of successful reviews resulting in claim payment.

Results for service specific post payment reviews are listed below.

Ambulance – A0428

Service Specific Results

Kentucky

Ohio

Reviews Completed

167

378

Claims Allowed

122

265

Claims Denied

45

113

No Provider Response

11

13

Screen Shot

Top Finding: The documentation submitted does not support medical necessity. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2External PDF.

  • The Physician Certification Statement and patient transport documentation did not support why other means of transportation were contraindicated.

Drugs/Biologicals – J0129, J0178, J2507

Service Specific Results

Kentucky

Ohio

Reviews Completed

3

9

Claims Allowed

1

4

Claims Denied

2

5

No Provider Response

0

0

Screen Shot

Top Finding: The documentation submitted does not support medical necessity. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2External PDF.

  • The submitted documentation lacked elements such as orders, purchase orders, patient signed consent, and progress notes supporting the medical necessity of the drug/biological administration.

Resources:

CGS Part B MR Activities

Provider inquiries and education requests may be email to J15BMREDUCATION@cgsadmin.com.

CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review activity log and by using tools such as Comparative Billing Reports (CBRs) offered through our web portal.

To learn more about the post payment resumptive process, please refer to the following links:

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