01-003 Hospital Outpatient Dental Services Notification of Medical Review
Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for outpatient dental services billed on dates of service from January 1, 2017 through December 31, 2017. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter and resources providers/suppliers may wish to consult when submitting claims.
The Office of Inspector General (OIG), under report A-06-16-05003, dated March 2017, found that 542 out of 600 dental services in the six stratified random samples did not comply with Medicare requirements. Based on these results, the OIG estimated that the six Medicare contractors improperly paid providers an estimated $9.7 million for hospital outpatient dental services that did not comply with Medicare requirements.
Reason for Review
In response to the OIG report, the CMS tasked Noridian, as the SMRC, to conduct medical review. The SMRC will medically review claims to determine if the dental service was eligible to be paid by Medicare and meets all other applicable requirements, based upon submitted medical documentation. Medicare generally does not cover hospital outpatient dental services, but these services may be covered under rare circumstances.
Claim Sample Detail
Access related project details below.
Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.
- Medical notes, operative report, radiology report, treatment plan, etc. to support the beneficiary’s medical condition for the billed service. This may include records supporting:
- cancer of the face or jaw requiring jaw reconstruction or teeth extraction
- reduction or wiring of jaw or facial bone related to trauma or fracture
- Legible handwritten or valid electronic signature and signature log, if applicable
- Physician or Non-Physician Practitioner (NPP) order for date of service, if applicable
- Advance Beneficiary Notice of Noncoverage (ABN), if applicable
- Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(a), (a)(7) and (a)(12). Exclusion from Coverage and Medicare as a Secondary Payer
- Social Security Act (SSA) Title XVIII, Section 1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
- Code of Federal Regulations Title 42, Section 411.15(i). Services Excluded from Coverage
- Code of Federal Regulations Title 42, Section 410.32(a). Ordering diagnostic tests
- Code of Federal Regulations Title 42, Section 410.32(a)(3). Ordering diagnostic tests-Application to non-physician practitioners
- Code of Federal Regulations Title 42, Section 440.100. Dental Services
- Medicare Benefit Policy Manual (MBIM), Pub. No. 100-02, Chapter 15, Section 150. Covered Medical and Other Health Services
- Medicare Benefit Policy Manual (MBIM), Pub. No. 100-02, Chapter 16, Section 140. General Exclusions from Coverage
- CMS Product No. 10050. Medicare & You 2018. November 2017. Centers for Medicare & Medicaid Services
Last Updated Feb 11, 2019