You may receive requests for medical records from Medicare for a variety of reasons. Requests may also come from several different Medicare contractors. Record requests may be related to any of the following:
- Review of a Medicare contractor through the Comprehensive Error Rate Testing (CERT) program
- More information is required before the Medicare contractor can process the claim
- Review of a new physician or practitioner to ensure a good understanding of Medicare claim submission and documentation guidelines
- Review of an established physician or practitioner, before or after the claim is paid, based on analysis of data
- Investigation of a complaint alleging possible fraud or abuse of the Medicare program
- Review of services by the Recovery Audit Contractor (RAC)
In all cases, it is imperative that you return the records to the requesting entity within the time frame specified.
Note: Your facility may have designated a single point of contact or coordinator for requests for medical records from Medicare contractors.
Check with your compliance officer or manager before submitting records or transferring the request to another department.
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Reason for Request (Medicare Part B)
|
Last Date to Submit Records
|
Return the Records To
|
| Review of a Medicare contractor, through the CERT program |
75 days from the date on the letter |
CERT Documentation Contractor (CDC)
Fax records (with CID and bar code sheet) to (240) 568-6222.
Physical address for CDC:
CERT Documentation Office
Attn CID # ________
9090 Junction Drive, Suite 9
Annapolis Junction, MD 20701 |
| More information is required before Medicare can process the claim (claim has not yet been paid) – also called an “automated development letter” |
45 days from the date on the letter |
Palmetto GBA
(the address will be listed at the bottom of the letter) |
| Review of records for a new physician or practitioner before the claim is paid |
45 days from the date on the letter |
Palmetto GBA
(the address will be listed at the bottom of the letter) |
| Review of claims by the Recovery Audit Contractor (RAC) |
45 days from the date on the letter
Review specifications for submitting paper and electronic medical records to Connolly Consulting |
Connolly Healthcare RAC Office
The Navy Yard Corporate Center
One Cresent Drive, Ste. 300-A
Philadelphia, PA 19112
|
|
Reason for Request (Medicare Part B)
|
Last Date to Submit Records
|
Return the Records To
|
| Review of an established physician or practitioner before the claim is paid |
45 days from the date on the letter |
Palmetto GBA
(the address will be listed at the bottom of the letter) |
| Review of an established physician or practitioner after the claim was paid |
30 days from the date on the letter |
AdvanceMed
3940 Gantz Rd Suite F
Grove City, OH 43123 |
| Investigation of a complaint alleging possible fraud or abuse |
30 days from the date on the letter |
AdvanceMed
3940 Gantz Rd Suite F
Grove City, OH 43123 |
It is also vital that you include all of the requested records. Before responding to the request, double-check to ensure that you have included all relevant information, such as:
- If the request is for a physician or nonphysician practitioner (NPP) visit (Evaluation & Management service, or E/M service) include documentation for that encounter:
- … and the physician/NPP’s note refers to an earlier encounter date (such as a prior history or list of prescription medications), include copies for the earlier note as well as information pertinent to the date requested
- … and the physician/NPP’s note refers to results of a lab or other diagnostic test, include the test results with the requested information
- … and the physician/NPP’s note refers to a form completed by the patient listing his or her symptoms or past history, copy this form along with the physician’s notes
- … and if the service is a consultation, copy the request from the referring physician to the consulting physician or your documentation of such, along with the physician’s written consultation report
- If the physician or practitioner’s signature is not legible, provide a key and indicate whose signature appears in the records
- If the physician or practitioner uses abbreviations that are not common, provide a key
- If the patient signed an Advance Beneficiary Notice (ABN), include a copy with the requested records
- If the service is the physician’s interpretation of a diagnostic test, such as an EKG or x-ray, provide his or her complete interpretation and copies of the test results. Do not send original x-ray films or other original records.
Other Tips:
- Each letter from Medicare requesting medical records will be on CMS letterhead and will include a telephone number. If you are unsure what information is being requested, call the number and ask questions to clarify.
- If the medical records are two-sided, copy both sides before sending copies to the requesting entity
- You may respond to medical record requests from Medicare contractors without having the patient sign additional HIPAA release forms. The patient’s signature on file, or his/her signature on the Medicare claim, authorizes release of the records to a Medicare contractor upon request.
- If the request is from Palmetto GBA and you have additional questions, please call the number listed in the letter. If you cannot locate the telephone number in the letter, please call us at (866) 332-7025.
- If the request is from AdvanceMed, call the specific telephone number listed in the letter
- If the request is from National Government Services, the Fiscal Intermediary (Part A) for West Virginia, please contact them directly with any questions or concerns at (877) 908-8474