SMRC – Path 1

1. CMS assigns a medical review project to the SMRC
2. Additional documentation request (ADR) letters are mailed to the providers and suppliers (P/S)
3. The providers and suppliers have 45 calendar days from the date of the ADR to return the documentation to the SMRC
4. The provider/supplier returns documentation
5. The SMRC has 30 calendar days to review the documentation
6. Upon completion of the review a Final Review Results letter is mailed to the provider or supplier
7. The provider or supplier has 14 days from the date of the final review results letter to contact the SMRC to request a discussion and education (D&E) session, and/or the SMRC of their intent to submit additional documentation to support the claims that were reviewed

SMRC – Path 1a – Provider/Supplier Returns Requested Documentation, Requests D&E/Relays Intent to Submit Additional Documentation, and Submits Additional Documentation for Re-review

1. The provider or supplier requests a discussion and education the SMRC schedules and conducts the discussion and education within 14 days of the discussion and education request.
2. Does the provider or supplier want to submit additional documentation for a re review?
3. The provider or supplier has 14 days from the discussion and education session to submit the additional documentation.
4. The SMRC will review the additional documentation
5. An updated Final Review Results letter is sent
6. The SMRC initiates claim adjustments through the Medicare Administrate Contractor (MAC)
7. The provider or supplier receives notice of an overpayment or underpayment from the MAC
8. The provider or supplier receives additional funds for underpaid claims or refunds any identified overpayments.
9. The provider or supplier requests an appeal through the MAC

SMRC – Path 1b – Provider/Supplier Returns Requested Documentation, Requests Re-review/Relays Intent to Submit Additional Documentation, and Submits Additional Documentation for Re-review

1. The provider or supplier does not request a discussion and education
2. The provider or supplier does request a re-review
3. The provider or supplier has 30 days from the date of the final review results letter to submit additional documentation.
4. The SMRC reviews the additional documentation within 30 days
5. An updated final review results letter is mailed to the provider or supplier
6. The SMRC initiates claim adjustments through the Medicare Administrate Contractor (MAC)
7. The provider or supplier receives notice of an overpayment or underpayment from the MAC
8. The provider or supplier receives additional funds for underpaid claims or refunds any identified overpayments.
9. The provider or supplier can request an appeal through the MAC if they disagree with the decision.

SMRC – Path 1c – Provider/Supplier Returns Requested Documentation, Does not Requests D&E or Re-review.

1. Provider or supplier does not request a Discussion and education session
2. Provider or supplier does not request a re-review
3. The SMRC initiates claim adjustments through the Medicare Administrate Contractor (MAC)
4. The provider or supplier receives notice of an overpayment or underpayment from the MAC
5. The provider or supplier receives additional funds for underpaid claims or refunds any identified overpayments.
6. The provider or supplier can request an appeal through the MAC if they disagree with the decision

SMRC – Path 2

1. CMS assigns a medical review project to the SMRC
2. Additional documentation request (ADR) letters are mailed to the providers and suppliers
3. The providers and suppliers have 45 calendar days from the date of the ADR to return the documentation to the SMRC
4. The provider/supplier does not return documentation
5. The claims are denied
6. A Final Review Results letter is mailed
7. The provider or supplier has 14 days to contact the SMRC to submit documentation and request the claims be reviewed.

SMRC – Path 2a – Provider/Supplier does not return Requested Documentation, Requests Re-review/Relays Intent to Submit Additional Documentation, and Submits Additional Documentation for Re-review

1. Provider or suppler submits documentation
2. The SMRC has 30 calendar days to review the documentation
3. An updated final review results letter is sent
4. If the provider or supplier requests a discussion and education session the SMRC schedules and conducts the discussion and education within 14 calendar days of the date of the request
5. If the provider or supplier does not request a discussion and education session or after the discussion and education session
6. The SMRC initiates claim adjustments through the Medicare Administrate Contractor (MAC)
7. The provider or supplier receives notice of an overpayment or underpayment from the MAC
8. The provider or supplier receives additional funds for underpaid claims or refunds any identified overpayments.
9. The provider or supplier can request an appeal through the MAC if they disagree with the decision

SMRC – Path 2b – Provider/Supplier Does not Returns Requested Documentation, Does not Request D&E or Re-review.

1. Provider or suppler does not submits documentation
2. The SMRC initiates claim adjustments through the Medicare Administrate Contractor (MAC)
3. The provider or supplier receives notice of an overpayment or underpayment from the MAC
4. The provider or supplier receives additional funds for underpaid claims or refunds any identified overpayments.
5. The provider or supplier can request an appeal through the MAC if they disagree with the decision

Definition Key:

CMS – Centers for Medicare and Medicaid Services

SMRC – Supplemental Medical Review Contractor

ADR – Additional Documentation Request

P/S – Provider/Supplier

D&E – Discussion and Education Session – Provider or Supplier can request to speak to the reviewer about the review results.

Re-Review – Provider or Supplier can request the claims be reviewed a second time with additional documentation.

MAC – Medicare Administrative Contractor

Last Updated Jan 28, 2022