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April 9, 2015

Supplemental Medical Review Contractor (SMRC) Project Resulting in Home Health Denials and Generating Overpayments

CGS is receiving questions in the Provider Contact Center about some home health claims that are being adjusted to deny services through the postpayment review process. These denials are the result of a SMRC review project.

Claims that were reviewed by the SMRC which resulted in a postpayment denial are being adjusted, and can be identified by the following indicators:

  • Type of bill = 32I
  • Status/location = D B9997
  • Reason code = 5SMRX (where X = 1-4)
  • Remark = Request for recovery of overpayment

Approximately 600 claims were adjusted. If you have claims that were affected by this SMRC project, please review the details of the SMRC project (Y1P18/Y2P18) and a sample additional development request (ADR) letter on the SMRC websiteExternal Website.

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