AHFI EXAM SCRIPT PREMIUM REVIEW
ACCURATE QUESTIONS AND CORRECT
ANSWERS
◉ For repeated infractions, MACs have.
Answer: The discretion to initiate progressively more severe
administrative action, commensurate with the seriousness of the
identified problem. (See Program Integrity Manual (PIM) chapter 3,
SS3. 7.1)
◉ Medicare Fee For Service Recovery Audit Program.
Answer: Legislative mandated program (Tax Relief and Health Care
act of 2006)
Utilizes Recovery Auditors to identify improper payments paid by
Medicare to fee-for-service providers.
Recovery Auditors identify improper payments
MACs adjust the claims, recoup identified overpayment and return
underpayment.s.
,◉ MACs targeted provider-specific prepayment review.
Answer: The MACs shall initiate a targeted provider-specific
prepayment review only when there is the likelihood of sustained or
high level of payment error.
MACs are encouraged to initiate service-s[ecific prepayment review
to prevent improper payments for services identified by C ERT or
Recovery Auditors as problem areas, as well as, problem areas
identified by their own data analysis
◉ Cert Contractors and reviews.
Answer: Because the Cert Contractors select claims on a random
basis, they are not required to notify providers of their intention to
begin a review.
◉ Prepayment Review Time Frames:.
Answer: When requesting documentation for prepayment reviews,
the Mac and ZPIC shall notify providers that the requested
documentation is to be submitted within 45-calendar days of the
request.
The reviewer shall Not grant extensions to providers who need more
time to comply with the request.
, Reviewers shall deny claims for which the requested documentation
was not received by day 46.
◉ Postpayment Review Time Frames.
Answer: When requesting documentation for postpayment review,
the Mac, Cert, and RAC shall notify providers that the requested
documents are to be submitted with 45-calendar days of the
request.
ZPIC shall notify providers that requested documents are to be
submitted with in 30-calendar days of the request.
◉ Additional Documentation Requests.
Answer: If information is requested from both the billing provider or
supplier and a third party and no response is received from either
within
45-calendar days for MACs and RACs
Or 30-days for ZPICs/UPICs
After the date of the request (or within a reasonable time following
an extension), the MACs, RACs and ZPICs/UPICs shall deny the claim
in full or in part as not reasonable and necessary.
ACCURATE QUESTIONS AND CORRECT
ANSWERS
◉ For repeated infractions, MACs have.
Answer: The discretion to initiate progressively more severe
administrative action, commensurate with the seriousness of the
identified problem. (See Program Integrity Manual (PIM) chapter 3,
SS3. 7.1)
◉ Medicare Fee For Service Recovery Audit Program.
Answer: Legislative mandated program (Tax Relief and Health Care
act of 2006)
Utilizes Recovery Auditors to identify improper payments paid by
Medicare to fee-for-service providers.
Recovery Auditors identify improper payments
MACs adjust the claims, recoup identified overpayment and return
underpayment.s.
,◉ MACs targeted provider-specific prepayment review.
Answer: The MACs shall initiate a targeted provider-specific
prepayment review only when there is the likelihood of sustained or
high level of payment error.
MACs are encouraged to initiate service-s[ecific prepayment review
to prevent improper payments for services identified by C ERT or
Recovery Auditors as problem areas, as well as, problem areas
identified by their own data analysis
◉ Cert Contractors and reviews.
Answer: Because the Cert Contractors select claims on a random
basis, they are not required to notify providers of their intention to
begin a review.
◉ Prepayment Review Time Frames:.
Answer: When requesting documentation for prepayment reviews,
the Mac and ZPIC shall notify providers that the requested
documentation is to be submitted within 45-calendar days of the
request.
The reviewer shall Not grant extensions to providers who need more
time to comply with the request.
, Reviewers shall deny claims for which the requested documentation
was not received by day 46.
◉ Postpayment Review Time Frames.
Answer: When requesting documentation for postpayment review,
the Mac, Cert, and RAC shall notify providers that the requested
documents are to be submitted with 45-calendar days of the
request.
ZPIC shall notify providers that requested documents are to be
submitted with in 30-calendar days of the request.
◉ Additional Documentation Requests.
Answer: If information is requested from both the billing provider or
supplier and a third party and no response is received from either
within
45-calendar days for MACs and RACs
Or 30-days for ZPICs/UPICs
After the date of the request (or within a reasonable time following
an extension), the MACs, RACs and ZPICs/UPICs shall deny the claim
in full or in part as not reasonable and necessary.
