Carriers ordered to be up-front with you when your claims get reviewed

Why This Topic Matters

The policy changes affect how practices receive notice during audits, how certain claims are returned or denied, and when documentation may be requested in lab-related reviews. Understanding the scope of the guidance can help organizations prepare for medical review activity and respond appropriately to carrier communications.

Article Sections

1. Program Integrity Manual changes and carrier review practices

   Introduces CMS guidance updates affecting how carriers conduct medical review and communicate with practices. Covers the broader context of pre- and post-payment audits and denial handling.

2. Claims handling, denial information, and workload expectations

   Describes changes related to how certain claim problems are communicated and how review workload should be managed. Also addresses transparency expectations for review findings and frequency-related issues.

3. Lab documentation requests spelled out

   Explains the documentation sequence CMS describes for laboratory claims during medical review. Focuses on the order in which carriers may seek records from the lab and the ordering provider.