Updates on the Therapy Limitation and Manual Medical Review Process for Therapy Threshold

Posted 05/16/2013

This article will serve to notify providers of an update to the Manual Medical Review Process for claims impacted by the 2013 Therapy Threshold.

Effective with claims submitted on 4/1/13 and later are subject to subject to the Manual Medical Review Process will be reviewed by the Recovery Auditor (RA) Contractor. Supporting medical documentation must be submitted to the RA at the address indicated on the request. RAs will complete two types of review:

  • Prepayment Review – Claims submitted in the RA Prepayment Review Demonstration states will be reviewed on a prepayment basis (National Government Services states of Illinois and New York). A request will be generated from National Government Services for the supporting documentation once a claim for payment is submitted. Instructions regarding submission of that documentation will be included on the request indicating submission should be to the appropriate RA.
  • Post payment Review – In the remaining states National Government Services will issue payment on impacted claims. The appropriate RA will then issue a request for the supporting documentation on paid claims to complete the review post payment. Documents should be submitted to the RA.

As a reminder, medical documentation must be forwarded to the appropriate RA and not to National Government Services. Supplying documentation to National Government Services may result in a delay of a determination on your claim.

Please visit our Web site under Review Process > Medical Review to review the complete information related to the Manual Medical Review Process for Therapy Threshold for 2013.


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