CMS determines review topics and time frames, and assigns the focus project to the SMRC (Noridian) via a formal notification. Noridian sends affected providers/suppliers an Additional Documentation Request (ADR) letter and, upon receipt of returned medical records and/or supporting documents, conducts the review based on the analysis of national claims data and in accordance with statutory, regulatory and sub regulatory coverage, coding, payment, and billing requirements.
Project Review Types
- Healthcare Fraud Prevention Partnership (HFPP) Support Review – Review based on fraud, waste, and abuse trends identified by the HFPP
- Program Integrity (PI) Support Review – Claim review focused on possible falsification or other evidence of alterations of medical record documentation including, but not limited to: obliterated sections; missing pages, inserted pages, white out; and excessive late entries; evidence that service billed for was actually provided and/or provided as billed; or, patterns and trends that may indicate potential fraud, waste, and abuse
- Provider Compliance Group (PCG) Review – Claim review based on evaluation of beneficiary’s information and supporting medical records to ensure that payment is made only for services that meet all Medicare coverage, coding, and medical necessity requirements
Access current projects below.
NOTE: At CMS discretion, not all projects will be made available on this website.
|Project ID||Project Title|
|01-003||Hospital Outpatient Dental Services|
|01-004||Specimen Validity Testing/Urine Drug Screen|
|01-006||Inpatient Bone Marrow and Stem Cell Transplant Procedures|
|01-009||General Inpatient Hospice|
|01-010||Replacement PAP Device Supplies and Accessories|
Post Review Options for Response
If a provider/supplier agrees with the SMRC medical review findings included within the Review Results Letter, follow the standard overpayment recovery process outlined by the MAC. If a provider/supplier disagrees with the decision according to the medical review findings, and the project is eligible for a Discussion & Education (D&E) Period, the Review Results Letter will contain process details. For more information, see the Discussion & Education (D&E) Period webpage.
Last Updated Feb 20, 2019