TRANSMITTAL ROUNDUP: Medicare Could Auto-Deny 100 Percent Of Suspicious Claims

Why This Topic Matters

The roundup highlights policy and processing changes that can affect claim acceptance, review activity, payer correspondence, drug reimbursement, and coding maintenance. Readers can use it to identify which Medicare operational updates may require internal follow-up.

Article Sections

1. High-risk claims areas and PSC review actions

   An overview of Medicare program safeguard contractor monitoring for suspicious billing patterns and related claims-control actions. The section also references the transmittal associated with these procedures.

2. NPI and UPIN matching updates

   Discussion of provider identifier crosswalk activity and carrier correspondence related to matching national provider identifiers with older identifier records. The section cites several transmittals tied to validation and system updates.

3. Medical Review documentation follow-up

   A summary of revised handling for claims lacking requested documentation in the medical review process. This section references the associated corrective-action transmittal.

4. Drug and biological payment policy updates

   Coverage and payment guidance affecting discarded portions of drugs or biologicals and other Part B drug payment updates. The section includes CMS transmittals related to payment amounts and drug reimbursement.

5. Diagnostic test reporting and code updates

   Administrative changes for purchased diagnostic tests and notice of code-related updates published by CMS. The section also notes new and updated coding information and medically unlikely edits.

6. Coverage, crossover claims, and code changes

   Additional transmittals addressing Medicare payment for selected services, coordination of benefits processing, and changes to recognized billing codes. The section reflects broader operational and claims-processing updates.