What criteria will be used by the RAC’s in determining the medical necessity of services related to a claim?
- Safe and effective;
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the Clinical Trials NCD, are considered reasonable and necessary); and
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member;
- Furnished in a setting appropriate to the patient's medical needs and condition;
- Ordered and furnished by qualified personnel;
- One that meets, but does not exceed, the patient's medical need; and
- At least as beneficial as an existing and available medically appropriate alternative.
RAC Scopes & Jurisdictions
Where can I learn what issues the RAC is reviewing?
Whose claims can be reviewed by the RAC?
Aren’t RAC’s focusing on hospital claims?
Do RAC’s review claims paid by Medicare Advantage Managed Care plans?
How far back can RAC’s look in reviewing claims?
Will RAC’s review claims for evaluation and management services?
RAC Review Criteria
How will RAC’s review claims for overpayments and underpayments?
What criteria will be used by the RAC’s in determining the medical necessity of services related to a claim?
RAC Recovery Requests
How can I identify a RAC recovery versus a request for refund from other sources?
If I disagree with an RAC’s overpayment findings, can I appeal?
Is there limitation on recovery of small overpayments found by the RAC?
Medical Record Review by the RAC
Must I allow the RAC to conduct an onsite review of my medical records?
Planning to Avoid RAC Issues
What should I do to protect my practice from RAC recovery efforts?
