Administrative Memos

200606

FROM: Theodore O. Will, Chief Executive Officer
DATE: Jun 07, 2006
SUBJECT: MEDICARE PREPAYMENT EXCLUSION REVIEW
IPRO CONTACTS:

Alice Vallar. Senior Director, Medicare/Federal Health Care Assessment at 516-326-7767, extension 423

In response to requests from the Hospital community, IPRO, the Quality Improvement Organization (QIO) for New York State is re-issuing the following information about Medicare Fiscal Intermediary (FI) referrals for prepayment review. Please note, there has been NO CHANGE in IPRO's review process.

When the FI rejects the hospital's claim for inpatient admission because the Principal Diagnosis and/or the Principal Procedure are potential exclusions from Medicare coverage, the FI directs the Hospital to submit the case to IPRO for review. Hospitals can facilitate submission of the medical record to IPRO for a prepayment review by following the procedure described below.

Provide:

A copy of the complete medical record (including operative reports);
A copy of the completed UB92 including the Diagnosis and Procedure ICD 9-CM codes exactly as they appeared on the claim that was rejected by the FI; and
A copy of the FI's rejection notice that displays the patient identifiers and the appropriate FI rejection code.
Attach the cover memo (see Exhibit A) and send the entire package to

IPRO

1979 Marcus Avenue

First Floor

Lake Success, New York 11042

ATTN: Alice Vallar, Senior Director, Medicare/Federal Health Care Assessment

IPRO cannot process your request for prepayment review without this information.

Should you have any questions or require additional information in regard to this memorandum, please contact Alice Vallar at 516-326-7767 x 423.