Supplemental Medical Review Contractor (SMRC)

Supported by the CMS, the SMRC, a Supplemental Medical Review Contractor, through the Center for Program Integrity, has been awarded to Noridian Healthcare Solutions, LLC (Noridian).

As the SMRC, Noridian performs and/or provides support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs.

With CMS directed topic selections and time frames, Noridian conducts nationwide medical reviews (Part A, Part B, and DME), in accordance with all applicable statutes, laws, regulations, national and local coverage determination policies, and coding guidance, to determine whether Medicare claims have been billed in compliance with coverage, coding, payment, and billing practices. Such reviews are assigned through CMS formal notifications and focus on analysis of national claims data issues identified by Federal agencies, such as the Office of Inspector General (OIG), Government Accountability Office (GAO), CMS internal data analysis, the Comprehensive Error Rate Testing (CERT) program, and professional organizations, and/or analysis reports such as First-Look Analysis Tool for Hospital Outlier Monitoring (FATHOM) report, and Program for Evaluating Payment Patterns Electronic Report (PEPPER). Reviews are based upon Provider Compliance Group (PCG), Program Integrity (PI), Healthcare Fraud Prevention Partnership (HFPP) project types.

Noridian must notify CMS of identified improper payments and noncompliance with documentation requests. We will initiate claim adjustments and/or overpayment recoupment via the standard overpayment recovery process.

Last Updated Nov 16, 2018