Credentials of Reviewers
I think someone posted a question about the credentials required for MAC
reviewers but cannot locate the email now. I found the following while
looking for something else. Don't know if it is what you were looking
for but hope it will help.
Medicare Program Integrity Manual
Chapter 3 - Verifying Potential Errors and Taking Corrective Actions
Table of Contents
(Rev. 426, 06-15-12)
3.3.1.1 - Complex Medical Review
(Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation:
06-28-11)
This section applies to MACs, CERT, Recovery Auditors, and ZPICs, as
indicated.
A. Credentials of Reviewers
The MACs, CERT, and ZPICs shall ensure that complex reviews for the
purpose of making coverage determinations are performed by licensed
nurses (RNs and LPNs) or physicians, unless this task is delegated to
other licensed health care professionals. Recovery Auditors shall ensure
that the credentials of their reviewers are consistent with the
requirements in the Recovery Auditor SOW.
During a complex review, nurse and physician reviewers may call upon
other health care professionals (e.g., dieticians or physician
specialists) for advice. The MACs, CERT, and ZPICs shall ensure that
services reviewed by other licensed health care professionals are within
their scope of practice and that their MR strategy supports the need for
their specialized expertise in the adjudication of particular claim type
(i.e., speech therapy claim, physical therapy). Recovery Auditors shall
follow guidance related to calling upon other healthcare professionals
as outlined in the Recovery auditor SOW.
The CERT and Recovery Auditors shall ensure that complex reviews for the
purpose of making coding determinations are performed by certified
coders. MACs are encouraged to make coding determinations by using
certified coders. ZPICs have the discretion to make coding
determinations using certified coders.
B. Credential Files
The MACs, CERT, Recovery Auditors, and ZPICs shall maintain a
credentials file for each reviewer (including consultants, contract
staff, subcontractors, and temporary staff) who performs complex
reviews. The credentials file shall contain at least a copy of the
reviewer's active professional license.
C. Quality
Sharon Salinas, CCS
Health Information Management Department
Barlow Respiratory Hospital
2000 Stadium Way
Los Angeles, CA 90026
ssalinas@barlow2000.org
Phone: 213-250-4200 ext. 3336
Fax: 213-202-6490
STATEMENT OF CONFIDENTIALITY Notice: This e-mail (including
attachments) is covered by the Electronic Communications Privacy Act, 18
U.S.C. 2510-2521, is confidential and is legally privileged. If you are
not the intended recipient, you are hereby notified that any retention,
dissemination, distribution, or copying of this communication is
strictly prohibited. Please reply to the sender that you have received
the message in error, then delete it.
P please consider the environment before printing this e-mail.
reviewers but cannot locate the email now. I found the following while
looking for something else. Don't know if it is what you were looking
for but hope it will help.
Medicare Program Integrity Manual
Chapter 3 - Verifying Potential Errors and Taking Corrective Actions
Table of Contents
(Rev. 426, 06-15-12)
3.3.1.1 - Complex Medical Review
(Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation:
06-28-11)
This section applies to MACs, CERT, Recovery Auditors, and ZPICs, as
indicated.
A. Credentials of Reviewers
The MACs, CERT, and ZPICs shall ensure that complex reviews for the
purpose of making coverage determinations are performed by licensed
nurses (RNs and LPNs) or physicians, unless this task is delegated to
other licensed health care professionals. Recovery Auditors shall ensure
that the credentials of their reviewers are consistent with the
requirements in the Recovery Auditor SOW.
During a complex review, nurse and physician reviewers may call upon
other health care professionals (e.g., dieticians or physician
specialists) for advice. The MACs, CERT, and ZPICs shall ensure that
services reviewed by other licensed health care professionals are within
their scope of practice and that their MR strategy supports the need for
their specialized expertise in the adjudication of particular claim type
(i.e., speech therapy claim, physical therapy). Recovery Auditors shall
follow guidance related to calling upon other healthcare professionals
as outlined in the Recovery auditor SOW.
The CERT and Recovery Auditors shall ensure that complex reviews for the
purpose of making coding determinations are performed by certified
coders. MACs are encouraged to make coding determinations by using
certified coders. ZPICs have the discretion to make coding
determinations using certified coders.
B. Credential Files
The MACs, CERT, Recovery Auditors, and ZPICs shall maintain a
credentials file for each reviewer (including consultants, contract
staff, subcontractors, and temporary staff) who performs complex
reviews. The credentials file shall contain at least a copy of the
reviewer's active professional license.
C. Quality
Sharon Salinas, CCS
Health Information Management Department
Barlow Respiratory Hospital
2000 Stadium Way
Los Angeles, CA 90026
ssalinas@barlow2000.org
Phone: 213-250-4200 ext. 3336
Fax: 213-202-6490
STATEMENT OF CONFIDENTIALITY Notice: This e-mail (including
attachments) is covered by the Electronic Communications Privacy Act, 18
U.S.C. 2510-2521, is confidential and is legally privileged. If you are
not the intended recipient, you are hereby notified that any retention,
dissemination, distribution, or copying of this communication is
strictly prohibited. Please reply to the sender that you have received
the message in error, then delete it.
P please consider the environment before printing this e-mail.