Did You Know? – Postpayment Review
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- What is Postpayment Review?
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As a Medicare Administrative Contractor (MAC), CGS Administrators, LLC is required by the Centers for Medicare and Medicaid Services (CMS) to analyze claims payment data in order to identify areas with the greatest risk of inappropriate program payment. CMS has authorized Jurisdiction 15 to conduct a postpayment review process.
The purpose of the claim review is to ensure documentation supports the reasonable and necessary criteria of the services billed and follows Medicare rules and regulations. CGS will conduct postpayment reviews of items/services provided prior to March 1, 2020.
Reviewed 09/22/2021
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- How are review topics/issues selected?
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Review topics are selected based on data analysis identifying high risk areas for improper payment. These areas are outlined in the MAC's Improper Payment Reduction Strategy, which is reviewed and approved by CMS. Review topics may also be directed per CMS instruction. CGS details active review topics in the Medical Review Activity Log.
Reviewed 09/22/2021
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- What items or services will be selected for postpayment review?
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The CGS website provides a Medical Review Activity Log showing what topics will be reviewed. Refer to the following for details.
- Part A Medical Review Activity Log
- Part B Medical Review Activity Log
- Home Health and Hospice Medical Review Activity Log
Reviewed 09/22/2021
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- What information do I need to submit with the additional documentation request (ADR)?
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An ADR letter will be sent on claims selected for review. This letter will include a list of beneficiary (s) and dates of service for documentation requested and specific elements needed to support the service on review. Please ensure the process for routing these documents to the person(s) responsible for submission is timely and effective. Inform your staff responsible for receiving the ADR letters and submitting the required documentation for this review. Authorization for the release of this information is included in Federal Law regulations reference 42 CFR 411.24(a), 424.5(a)(6) and 44 USC 3101.
Reviewed 09/22/2021
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- How long do I have to return documentation?
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If the requested documentation is not returned within 45 days, the claims will be denied due to lack of documentation and could potentially result in overpayment recoupment. It is your responsibility as a provider to provide the requested documentation within the allotted time frame. Additionally, if providers/suppliers do not respond to the ADR requests, MACs have the option to refer to the Recovery Auditor Contractor (RAC) or Unified Program Integrity Contractor (UPIC).
Reviewed 09/22/2021
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- How and when will I be notified of my results?
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Upon completion of our review, you will receive a results letter including allowed or denied claims with estimated overpayment amounts if applicable and education will be provided upon request.
CGS has 60 days from the date the documentation is received to review and render claim determination
Reviewed 09/22/2021
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- What happens after review completion?
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If the claim is denied in part or in full, the final demand letter will be sent by Overpayment Recovery department. Do not take any action until you receive the final demand letter.
Reviewed 09/22/2021
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- How can I request education?
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Education may be provided upon request, using the appropriate email for your provider type below.
- Part A: J15AMREDUCATION@CGSADMIN.COM
- Part B: J15BMREDUCATION@CGSADMIN.COM
- HHH: J15HHMREDUCATION@CGSADMIN.COM
Reviewed 09/22/2021
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- What if I have questions while under review?
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You may send questions using the appropriate email for your provider type below.
- Part A: J15AMREDUCATION@CGSADMIN.COM
- Part B: J15BMREDUCATION@CGSADMIN.COM
- HHH: J15HHMREDUCATION@CGSADMIN.COM
Reviewed 09/22/2021
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- Can I appeal these claims?
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When a claim is denied with reason code 56900 indicating that the medical documentation was not received by CGS, or was not received timely, a "56900 reopening" may be requested to have the medical documentation reviewed by the Medical Review department, without utilizing the Medicare Appeals Process. All other denials for which the provider disagrees may be appealed using the Medicare Appeals Process.
For more information about appeals, refer to the web pages blow.
- Part A Appeals/Redeterminations
- Part B Appeals/Redeterminations
- Home Health and Hospice Appeals/Redeterminations
Reviewed 09/22/2021
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