What are Review Reason Statements?

  • esMD introduced the ability to electronically exchange medical documentation between the Health Information Handlers (HIHs, who represent the Medicare Provider Community) and the Medicare RCs.

  • When the RCs complete review of a medical claim, in case of a denied/non-affirmed decision, the review contractor has to provide a detailed denial/non-affirmed reason to the billing provider/supplier.

How are they being created?

  • CMS has been working with the Medicare Administrative Contractors (MACs), Recovery Auditors (RAs) and Supplemental Medical Review Contractor (SMRC) to develop standardized review reason codes and corresponding detailed reason statements for the Medicare Fee-for-Service (FFS) medical reviews.

  • These standardized codes and statements are to be used for all reviews including pre-pay, post-pay, prior authorization and pre-claim reviews.

How are they maintained?

  • CMS will add new sets and issue quarterly updates to the existing reason statements sets and publish the latest versions on the CMS website. CMS expects the contractors to keep up to date with the latest posted reason statements versions and use them as applicable and appropriate.

  • The RCs will be able to send any updates, feedback, or suggestions to the published reason codes and statements sets via email to   PCG-ReviewStatements@cms.hhs.gov  for consideration to review and act accordingly in the next Review Statements Change Control Board (CCB).