Discussion & Education Period
Once the review is completed, providers/suppliers will be notified through a Review Results Letter containing claim(s) and the specific review findings associated with such claim(s). If a provider/supplier agrees with the SMRC findings, the standard overpayment recovery process shall be followed. If a provider/supplier disagrees with the SMRC findings, a Discussion & Education (D&E) session with Noridian may be available and must be requested. The final review results letter shall also notify the provider/supplier that they may elect to submit missing documentation but decline a D&E session.
The D&E period is intended to allow for the communication of the payment recommendations, discussion of the rationale for the medical review findings, education about coverage, coding and payment policies for the subject claim to avoid future denials and provide another opportunity to submit missing documentation.
Providers/Suppliers May Request a D&E Session for Eligible Projects
- Review Results Letter states that a request for a D&E must be submitted via telephone, electronically, or in writing within 14 days of Review Result Letter date
- We (Noridian, the SMRC) shall aim to hold a D&E session within 14 days of receipt of provider/supplier D&E request. A D&E session shall include, among other things, letting provider/supplier know what documentation was missing
- If during a D&E session, provider/supplier notes he/she wants to submit documentation that was not included in their original documentation submission, they may do so within 14 days of D&E session date
- After we receive the missing documentation, identified during provider/supplier D&E session, we shall conduct a re-review within 14 days of receipt of the new documentation and consider the recently received documentation
- Once we complete re-review, a revised final results letter will be sent to the provider/supplier within a reasonable time, generally 7 days
Providers/Suppliers May Submit Missing Documentation But Decline a D&E Session
- Convey intent to submit additional documentation and request a re-review considering this documentation within 14 days of final results letter date
- Submit documentation to support payment of denied claim(s). This additional documentation must be received by Noridian within 30 days from Review Results Letter date
- Requests and documentation received after this time frame are considered invalid. No further review will occur. Provider/supplier will be notified of this in writing
D&E Request Details and Re-Review Requests Without a D&E
D&E session requests re-review without a D&E session requests must be submitted to Noridian via telephone, electronically, or in writing within 14 days of Review Results Letter date and must include:
- Provider/Supplier name
- National Provider Identifier (NPI)
- Provider/Supplier representative name
- Phone number
- Fax number
- Number of claims submitted within request
Each claim submitted within a request must include:
- Project sample ID
- Beneficiary’s name
- Beneficiary’s date of birth
- Claim number
- Date(s) of service
This information is included in the Review Results Letter.
We recommend one request per issue; however, multiple claims reviewed for the same project may be included within a single request.
Attach a copy of the Review Results Letter for the project in question and identify which claims are to be included in the D&E Period.
Request Submission Options
- Email – Do not include medical records documentation or any other form of Protected Health Information (PHI) or Personally Identifiable Information (PII)
- Fax – Verify successful transmission by printing a confirmation report. We recommend requestors track all communications throughout D&E Period
- Mail – Use a traceable method with delivery confirmation
Contact the SMRC Contact Center with related questions.
Last Updated Nov 15, 2018