Noridian Healthcare Solutions LLC (Noridian) is the SMRC under contract with CMS to perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid Programs.
Noridian was selected by CMS to conduct nationwide medical reviews as directed by CMS. Noridian conducts nationwide medical reviews (Part A, Part B and DME), in accordance with all applicable statutes, laws, regulations, national and local coverage determination policies, and coding guidance, to determine whether Medicare claims have been billed in compliance with coverage, coding, payment, and billing practices. Such reviews are assigned through CMS formal notifications and focus on analysis of national claims data issues identified by federal agencies, such as the OIG, GAO, CMS internal data analysis, the CERT program, and professional organizations, and/or analysis reports such as FATHOM report and PEPPER.
One of the primary tasks will be conducting nationwide medical review as directed by CMS. The medical review will be performed on Part A, Part B and DME providers and suppliers. Services/provider specialties to be reviewed will be selected by CMS, Provider Compliance Group/DMRE. The SMRC will evaluate medical records and related documents to determine whether Medicare claims were billed in compliance with coverage, coding, payment and billing practices. To achieve the goal of the CMS Medical Review program, the SMRC will:
The SMRC will be performing medical review in accordance with CMS regulations, the CMS IOM Publication 100-08, Medicare Program Integrity Manual and other current and future CMS Provider Compliance Group/Division of Medical Review and Education initiatives.
The focus of the reviews may include, but is not limited to vulnerabilities identified by CMS internal data analysis, the CERT program, professional organizations and federal oversight agencies, such as the OIG.
Noridian has a responsibility to notify CMS of any identified improper payments and noncompliance with documentation requests. The Medicare Administrative Contractors may initiate claim adjustments and/or overpayment recoupment actions through the standard overpayment recovery process.
The following resources are available on the Noridian Healthcare Solutions LLC website:
The SMRC Contact Center is available:
Noridian Healthcare Solutions LLC is the SMRC to review Medicare Part A HHA claims for the purpose of performing CMS-directed documentation-only review to validate that the most recent and valid face-to-face encounter is documented. The goal is to lower improper payment rates and increase efficiencies of the Medicare Program’s medical review function.
The SMRC uses the address available in PECOS to send ADRs for medical records. Due to the ADRs being returned to the SMRC for an insufficient or incorrect provider address, several HHA claims denied because HHA records were not received.
To ensure that ADRs are sent to the appropriate address, it is important that providers verify the address that is in the PECOS.
