Medicare Exclusion Review

Medicare pays for reasonable and medically necessary medical care provided to a Medicare beneficiary. Medicare does not pay for cosmetic, dental or sterilization procedures. There are numerous other procedures that have very specific guidelines for Medicare coverage. These guidelines are found in the Medicare Coverage Issues manual. When claims are filed for one of the procedures, Medicare requests that AFMC review the medical record and determine if the procedure is appropriate. These claims are suspended pending outcome of review. The medical record will be requested from the hospital medical record department by AFMC. When the entire medical record for the indicated admission is received, review will be performed. If the admission or procedure cannot be approved by the reviewing nurse, physician review will be required.

The AFMC review process requires that providers be notified of potential denials and allowed 30 days to respond to the potential denial. Because of Medicare requirements, our review process can be rather lengthy. If you have not received payment within 90 days of mailing the chart to AFMC, you may contact Suzanne Martin, RHIA  in our review department for information.