Once the review is completed, provider/suppliers will be notified through a Review Results Letter containing claim(s) and the detailed review findings associated with those claim(s). If a provider/supplier agrees with the SMRC findings, the standard overpayment recovery process should be followed. If a provider/supplier disagrees with the SMRC findings, a voluntary Discussion & Education (D&E) session with Noridian may be available upon request. Provider/suppliers requesting a D&E session should reference the Review Results Letter for specific instructions on how to proceed. The final Review Results Letter will also notify the provider/supplier that they may elect to submit missing documentation but decline a D&E session.

The D&E period is intended to allow for the communication of the payment recommendations, discussion of the rationale for the medical review findings, education about coverage, coding and payment policies for the subject claim to avoid future denials and provide another opportunity to submit missing documentation.

A Re-Review is intended for providers/suppliers who upon receipt of the final review results understand the rationale for the medical review findings and realize they did not submit all documentation to support the services rendered. Requesting a re-review allows providers/suppliers the opportunity to submit additional documentation for review. Once the re-review is completed, a new final review results letter will be sent.

Providers/suppliers are not required to request any further action if they agree with the findings.

Providers/Suppliers May Request a D&E Session for Eligible Projects

• Review Results Letter states that a request for a D&E must be submitted via telephone, electronically, or in writing within 14 days of Review Result Letter date
• We (Noridian, the SMRC) shall aim to hold a D&E session within 14 days of receipt of provider/supplier D&E request. A D&E session shall include, among other things, letting provider/supplier know what documentation was missing
• If during a D&E session, provider/supplier notes he/she wants to submit documentation that was not included in their original documentation submission, they may do so within 14 days of D&E session date
• After we receive the missing documentation, identified during provider/supplier D&E session, we shall conduct a re-review within 14 days of receipt of the new documentation and consider the recently received documentation
• Once we complete re-review, a revised final results letter will be sent to the provider/supplier within a reasonable time, generally 7 days

Providers/Suppliers May Submit Missing Documentation But Decline a D&E Session

• Convey intent to submit additional documentation and request a re-review considering this documentation within 14 days of final results letter date
• Submit documentation to support payment of denied claim(s). This additional documentation must be received by Noridian within 30 days from Review Results Letter date
• Requests and documentation received after this time frame are considered invalid. No further review will occur. Provider/supplier will be notified of this in writing

D&E Session Request Details and Re-Review Requests Without a D&E

D&E session requests or re-review without a D&E session requests must be submitted to Noridian via telephone, electronically, or in writing within 14 days of Review Results Letter date and must include:

• Project ID
• National Provider Identifier (NPI)
• Provider Transaction Access Number (PTAN)
• State
• Three dates and times that D&E could be scheduled (typically scheduling 2-3 weeks out) if requesting a D&E session
• Company/Organization
• Contact Phone Number

This information is included in the Review Results Letter.

We recommend one request per issue; however, multiple claims reviewed for the same project may be included within a single request.

Attach a copy of the Review Results Letter for the project in question and identify which claims are to be included in the D&E Period.

Request Submission Options

• Email – Do not include medical records documentation or any other form of Protected Health Information (PHI) or Personally Identifiable Information (PII)
• Fax – Verify successful transmission by printing a confirmation report. We recommend requestors track all communications throughout D&E Period
• Mail – Use a traceable method with delivery confirmation
• Telephone – Contact the SMRC Contact Center with related questions.

Last Updated Mar 22, 2024