Noteworthy News

CMS Offers Additional Guidance on “Two-Midnight Rule”

The Centers for Medicare & Medicaid Services (CMS) has issued additional information about its plans for implementing the so-called Medicare two-midnight rule.

The rule, which officially took effect last August, has been the subject of controversy, questions, and clarifications ever since, with CMS issuing addiitonal guidance last September and again this last month.

Among other things, CMS’s latest guidance explains that

CMS is requesting that the Medicare Administrative Contractors (MACs) re-review all claim denials under the Probe & Educate process to ensure the claim decision and subsequent education is consistent with the most recent clarifications.  The MAC may reverse their decision and issue payment outside of the appeals process if the MAC determines that a claim is payable upon re-review by the MAC.  Therefore, CMS urges providers to work with their MACs to determine if a claim has undergone final adjustment (in other words, has been re-reviewed) prior to submitting an appeal request. To ensure that the re-review process does not affect the ability of a provider to file a timely appeal of a denied claim, CMS will waive the 120 day timeframe for filing redetermination requests received before September 30, 2014 for claim denials under the Probe & Educate process that occurred on or before January 30, 2014.


cmsClaim denials under the Probe & Educate process that occurred on or before January 30, 2014 for which an appeal has been filed will also be subject to re-review.  Claims determined payable following re-review will be adjusted accordingly.  Claims for which the denial is affirmed following re-review will be transferred to appeals automatically for a redetermination.

For further information, see the complete notice here, on the CMS web site.

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