The Centers for Medicare & Medicaid Services (CMS) contracts with a Supplemental Medical Review Contractor (SMRC) to help lower improper payment rates and protect the Medicare Trust Fund. The SMRC conducts nationwide medical reviews of Medicaid, Medicare Part A/B, and DMEPOS claims to determine whether claims follow coverage, coding, payment, and billing requirements. The focus of the medical reviews may include vulnerabilities identified by CMS data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations, and Federal oversight agencies. At the request of CMS, the SMRC may also carry out other special projects to protect the Medicare Trust Fund.
Additional Documentation Requests
Noridian Healthcare Solutions, the current SMRC, will send requests to providers and suppliers for additional documentation on claims selected for medical review. These requests comply with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which allows for the release of information for treatment, payment, and healthcare operations. Sections of the Social Security Act provide guidance that prohibits Medicare from making Part A or Part B payments until sufficient information and/or documentation has been furnished to determine the amounts due.
Noridian Healthcare Solutions will notify CMS of any identified improper payments and noncompliance with documentation requests. The Medicare Administrative Contractor (MAC) may initiate claim adjustments and/or overpayment recoupment actions through the standard recovery process.
If you have questions about the overpayment recovery process or appeal rights, find and contact your MAC using the review contractor directory. For more details on the SMRC program, contact Noridian Healthcare Solutions at 1-833-860-4133, or visit Noridian Healthcare Solutions’ SMRC website at https://www.noridiansmrc.com/.