(Medicare Program Integrity Manual)

The first paragraph in the ADR may identify the following:   The program purpose;   Where additional information about the program and regulations can be found, for example, a website reference; and   Additional program information that may be helpful to the provider or supplier.  B. Reason for Selection   The reason the provider or supplier was sent the ADR le tter and notes about the claims under review.   C. Action  The action(s) the provider or supplier shall take as a result of receiving the ADR letter.   D. When  The date a provider/supplier shall reply to the ADR letter and submit the documentation to the contractor.   E. Consequences  The consequences if the provider or supplier fails to submit the requested documentation.   F. Instructions  Instructions and notes that will help the provider or supplier respond to the ADR letter.   G. Submission Methods  The methods the provider or supplier can submit the requested documentation.   H. Questions  Contractor contact information for provider inquiries related to the ADR.   I. Attachments / Supplementary Information   If there are attachments or other supplementary info rmation associated with the ADR, provide a listing of the attachment titles or provide the supplementary information.  3.2.3.5 - Acceptable Submission Methods for Responses to ADRs  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, Recovery Auditors, CERT, and UPICs, as indicated.   Reviewers shall be clear in their ADR letters about what documentation submission methods they will accept from a provider or Health Information Handler (HIH). The MACs, CERT, and Recovery Auditors shall accept documents via paper, fax, CD/DVD, and electronic submission of medical documentation (esMD).   A. Paper   The MACs, CERT, and Recovery Auditors are encouraged to state in the ADRs that paper medical documentation c an be mailed by any means including US Postal Service, FedEx, UPS, or certified mail. To facilitate delivery of documentation, MACs, CERT and Recovery Auditors should provide a physical mailing address instead of a P.O. Box.  B. Fax  If the MACs, CERT, or Recovery Auditors have the capability to offer fax confirmation, they are encouraged to send such confirmations with every successfully received fax.   C. Imaged Medical Documentation File(s) Sent on  CD/DVD   The MACs and CERT shall state in the ADR that imaged medical documentation files on CD/DVD may be mailed by any means. Recovery Auditor ADRs shall provide a Web site link or phone number that provides information regarding the requirements for submitting imaged documentation on CD or DVD.   D. Medical Documentation Sent via Electronic Submission of Medical Documentation (esMD) Transmission   Electronic Submission of Medical Documentation (esMD) is a system that allows providers/HIHs to submit medical documentation over secure electronic means. Information about the esMD system can be found at www.cms.gov/esMD.   MACs and CERT are encouraged to state in their ADRs how providers can get more information about submitting medic al documentation via the esMD mechanism.   Any time a new esMD service or document type is being offered, and any contractor wants to publish a public announcement (Web posting, list serve, tweet, etc.) the contractor must clear the announcement with CMS.  3.2.3.6 - Reimbursing Providers and HIHs for Additional Documentation  (Rev.  786, Issued: 04-13-18, Effective: 05-14-18, Implementation: 05-14-18)   A. General   1. Rules  for MACs,  SMRC,  CERT,  and UPICs    The MACs,  SMRC,  CERT,  and UPICs  are not required  to pay for medical  documentation for either  prepayment or post payment review.   2. Rules  for RACs    RACs  performing  post payment review  of hospital inpatient prospective payment system  (PPS)  and long term  care facilities  are required  to pay the providers for submitting requested  medical  records.  RACs  shall  pay according to  the payment  rate schedule listed  in section  B below.    RACs  performing  post payment review  of provider types other than  hospital inpatient PPS and  long term  care facilities  are required  to pay the providers for submitting  requested  medical  records,  according to  the payment rate schedule listed  in section  B below.    Providers under a Medicare reimbursement system (such as Critical Access Hospitals) receive no reimbursement for submitting medical records.    RACs shall pay a maximum of $15.00 per record, including first class postage if applicable, for requested documents submitted via mail/fax/CD/DVD.    RACs shall pay a maximum of $27.00 per record, including a transaction fee of $2.00/case, for requested documents submitted via esMD.   Payments will not be made for blank pages or documents/records that are not related to the claim being reviewed.    RACs shall issue documentation submission payments on at least a monthly basis and shall issue all photocopying payments within 45 calendar days of receiving the documentation.  RACs shall honor all requests from providers to issue photocopying payments to HIHs. RACs should gather, from the provider, all necessary information, such as, the HIHs name, phone number and bank routing number, etc.   Providers interested in submitting documentation via esMD can find information on the CMS esMD website at http://www.cms.gov/esMD.   B. Payment Schedule  for Requested  Medical  Records    Hospital  Inpatient  Prospective  Payment  System  (PPS)  Facilities   and Long  Term  Care  Facilities  Non-PPS Institutions  and Practitioners  Documentation  sent via mail,  fax, CD/DVD  - 12 cents per page - Plus first class postage, if applicable  - $15.00 maximum per record  - 15 cents  per page  - Plus first  class  postage, if  applicable  - $15.00 maximum per  record   Documentation  sent via esMD  - 12 cents per page  - Plus $2.00 transaction fee, per record  - $27.00 maximum per record  - 15 cents per page  - Plus $2.00 transaction  fee, per case - $27.00 maximum per record    *Note: Providers under a Medicare reimbursement system (such as Critical Access Hospitals) receive no reimbursement for submitting medical records. Also, payments will not be made for blank pages or documents/records that are not related to the claim being reviewed.   3.2.3.7 - Special Provisions for Lab Additional Documentation Requests  (Rev. 10365; Issued : 10-02-20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, CERT, RACs, UPICs, and SMRC as indicated.   ICD-10-CM is used for diagnoses on inpatient discharges and for other services provided upon implementation of ICD -10. ICD -9-CM is used for discharges and other services before that implementation.   When the MACs, CERT, RACs, and UPICs send an ADR for a lab service, the following documentation shall be requested from the billing lab:   The order for the service billed (including sufficient information to allow the reviewer to identify and contact the ordering provider);   Verification of accurate processing of the order and submission of the claim; and   Diagnostic or other medical information supplied to the lab by the ordering provider, including any diagnosis codes or narratives.   The contractor shall deny the claim if a benefit category, statutory exclusion, or coding issue is in question, or send an ADR to the ordering provider in order to determine medical necessi ty. The contractor shall review information from the lab and find it insufficient before the ordering provider is contacted. The contractor shall send an ADR to the ordering provider that shall include sufficient information to identify the claim in question.  If the documentation received does not demonstrate that the service was reasonable and necessary, the contractor shall deny the claim. These denials count as medical record reviews. Contractor denial notices shall remind providers that beneficiaries cannot be held liable for these denials unless they have received proper liability notification before services were rendered, as detailed in CMS Pub. IOM 100-04, chapter 30.  3.2.3.8 - No Response or Insufficient Response to Additional Documentation Reques ts (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, RACs, CERT, SMRC, and UPICs, as indicated.   A. Additional Documentation  Requests   The reviewer authority to request that documentation be submitted, to support claims payment, is outlined in Section 3.2.3.2 of this chapter.  If information is requested from both the billing provider or supplier and/or a third party and no response is received within the expected timeframes (or within a reasonable time following an extension), the MACs, RACs, SMRC, and UPICs shall deny the claim, in full or in part, as not reasonable and necessary. Contractors shall use Group Code:  CO -  Contractual Obligation and Claim Adjustment Reason Code (CARC) 50 -  these are non -covered services because this is not deemed a medical necessity by the payer  and Remittance Advice Remark Code (RARC) M127 - Missing patient medical record for this service.   MACs shall count these denials as automated review or non- medical reco rd review depending whether the denial is automated or requires manual intervention. For claims that had a PWK modifier, and the unsolicited documentation was reviewed, the review shall be counted as medical record review .  B. No Response   During prepayment r eview, if no response is received within the expected timeframes, the MACs and UPICs shall deny the claim.   During post -payment review, if no response is received within the expected timeframes (or extension), the MACs, RACs, UPICs and SMRC shall deny the claim as not reasonable and necessary. These contractors shall cite sections 1815(a), 1833(e), and 1862(a)(1)(A) of the Act exclusively when referring to the authority for requiring submission of documentation, when denying claims for no response within the expected timeframes. The MACs shall count these denials as non- medical record reviews .  C. Insufficient  Response   If the MAC, CERT, RAC, SMRC, or UPIC requests additional documentation to verify compliance with a benefit category requirement, and the submitted documentation lacks evidence that the benefit category requirements were met, the reviewer shall issue a benefit category denial. If the submitted documentation includes defective information (the documentation does not support the physicians ce rtification), the reviewer shall deny the claim as not meeting the reasonable and necessary criteria.   3.2.3.9 - Reopening Claims with Additional Information or Denied due to Late or No Submission of Requested Information  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  Contractors shall make available general reopening process information via their website, in their ADR letters, or through remittance advice notices.  If the MACs receive the requested information from a provide r or supplier after a denial has been issued but within a reasonable number of days (generally 15 calendar days after the denial date), they have the discretion to reopen the claim. MACs who choose to reopen a specific claim shall notify the provider or supplier of their intent to reopen that claim. Notification to the provider/supplier of the intent to reopen a specific claim shall be completed through any of the following mechanisms: Interactive Voice Response (IVR), contractor website portal, telephone c ontact, by letter, fax, email or secure messaging within 3 business days of identification of the request to reopen or receipt of medical record documentation. MR will make an MR determination on the lines previously denied due to failure to submit request ed documentation, and do one of the following, within 60 calendar days of receiving documentation in the mailroom:    For claims originally selected for postpayment review, the reviewer shall issue  a new letter containing the revised denial reason and the information required by PIM chapter 3 3.6.4;    For claims originally selected for prepayment review, the MAC shall enter the revised MR determination into the shared system, generating a new Medicare Summary Notice (MSN) and remittance advice with the new denial reason  and appeals  information;    The workload, costs, and savings associated with this activity shall be allocated to the appropriate MR activity (e.g., MR  reopenings);