Becker's Healthcare November 7, 2023
CMS is proposing a standard appeals process for risk adjustment data validation audits in Medicare Advantage.
CMS issued its 2025 Medicare Advantage proposed rule on Nov. 6. In the rule, CMS proposed MA organizations be able to request a medical record review determination appeal or payment error calculation appeal, but not both at the same time.
Under the proposed rule, plans can only request a payment error calculation appeal after the medical record review is completed. The proposed rule would also establish that if the CMS administrator does not accept or decline an appeal within 90 days of receiving the appeal, the audit becomes final.
Under current rules, appeals move through the medical record and payment error...
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