What must be true for a claim to go through a Complex Review in a RAC audit?

For a claim to undergo a Complex Review in a Recovery Audit Contractor (RAC) audit, it must be established that there is a high probability that the service is not covered by Medicare. This criterion is essential because the purpose of Complex Reviews is to thoroughly evaluate claims that present potential issues regarding coverage, ensuring that the claims submitted align with Medicare guidelines.

When a high probability of non-coverage exists, it indicates that further scrutiny is warranted to determine whether the services provided meet the necessary criteria for payment. This often involves analyzing medical documentation and other evidence to assess compliance with Medicare policies.

While clear medical policy violations and claim value can play important roles in the audit process, the determining factor for triggering a Complex Review is the assessment of coverage under Medicare. The claim submitter's request also does not influence the necessity for a Complex Review since that determination is based on established criteria rather than individual inputs. Therefore, the focus on coverage probability is what primarily drives the decision for a Complex Review in a RAC audit context.