(Medicare Program Integrity Manual)

Providers interested in submitting documentation via esMD can find information on the CMS esMD website at http://www.cms.gov/esMD.   A.  Outcome Assessment Information Set (OASIS)   Medicares Home Health PPS Rate Update for CY 2010 final rule, published in the November 10, 2009 Federal Register, includes a provision to require the submission of the OASIS as a condition of payment, that is codified in regulations 42 CFR484.210(e). Beginning January 1, 2010, home health agencies (HHAs) are required to submit an OASIS as a condition for payment. The MACs shall deny the claim if providers do not meet this regulatory requirement. The assessment must be patient specific, accur ate and reflect the current health status of the patient.  This status includes certain OASIS elements used for calculation of payment.  These include documentation of clinical needs, functional status, and service utilization.  B.  Plan of Care (POC)   Com prehensive care planning is essential to good patient care under the Medicare program. In fact, it is specifically written into the coverage and/or certification requirements for a number of healthcare settings.  For purposes of the Part A benefit for home  health, inpatient rehabilitation facility and hospice, the Social Security Act describes criteria and standards used for covering these services.  This includes establishing an individualized POC.  The POC identifies treatment goals and coordination of se rvices to meet patient needs as set forth in CFR 418.200 requirement for coverage.  The POC must be established by a physician(s).  However, in the case of a hospice, in addition to the physician, an interdisciplinary group shall establish a POC.  Section  1814(a)(2)(C), Part B 1835(a)(2)(A) of the Act, and CFR 409.43 state that a POC established by a treating physician must contain all pertinent information, such as, the patient history, initial status, treatment goals, procedures/services duration, and progress notes.   CFR412.622 requires an individualized POC by a rehabilitation physician that meets the requirements listed in the regulation.  MACs shall deny the claim as not meeting statutory requirements under the Social Security Act when the provider of services fails to comply with the POC requirements.   Pursuant to 42 CFR 489.21, a provider of services shall not charge a beneficiary for services that have been denied for the reasons stated above.   3.2.3.2 - Time - Frames for Submission  (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.   In certain circumstances, the MACs, CERT, SMRC, RACs, UPICs and other contractors may not be able to make a determination on prepayment or post -payment claims they have chosen for review based upon the information on the claim, its attachments, or the billing history found in claims processing system (if applicable) or the Common Working File (CWF). In those instances, the reviewer shall solicit documentation from the provider or supplier by issuing an ADR.   Contractors are authorized to collect medical do cumentation by the Social Security Act (the Act).   Section 1815(a) of the Act states that "no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period."   Section 1833(e) of the Act states that "[n]o payment shall be made to any provider of services or other person under this part unless there has bee n furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period."   In addition, Contractors are required to ensure that payment is limited to those items and services that are reasonable and necessary.   Section 1862(a)(1)(A) of the Act states that [n]otwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services   which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body m ember.   Contractors are required, when authoring correspondence related to ADRs, to 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.  A. Prepayment Review Time Frames   When requesting  documentation for prepayment review, the MACs and UPICs shall notify providers when they expect documentation to be received. The reviewer should not grant extensions to providers who need more time to comply with the re quest. Reviewers shall deny claims when the  requested documentation to support payment is not received by the expected timeframe.  B. Post-payment Review Time Frames   When requesting  documentation for post -payment review, the MACs, CERT, SMRC, UPICs and RACs shall notify  providers when they expect documentation to be received. MACs, CERT, SMRC, UPICs and RACs have the discretion to grant extensions to providers who need more time to comply with the request.   The MACs, CERT, SMRC, UPICs and RACs shall deny cla ims when the requested documentation to support payment is not received by the expected timeframe (including any applicable extensions) .  C. For esMD  submissions   The esMD  review contractor shall use the Enterprise File Transfer (EFT) system receipt date as the date the documentation was received. If the EFT receipt date is outside of the contractors normal business hours, the following business day shall be used as the rec eipt date. Contractors shall pull for esMD files at least every 4 hours (business hours) daily; including a mandatory pulling between the hours of 6- 7pm EST daily. If unforeseeable circumstances occur, in which contractors are not technically capable of re trieving documentation in a timely manner due to issues outside of their control, contractors are to notify the esMD Team and can use the date documentation was available to be retrieved once issues have been resolved in the EFT system.    3.2.3.3 - Third -party Additional Documentation Request  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, RACs, CERT and UPICs, as indicated.   Unless otherwise specified, the MAC, RAC and UPIC shall reques t information from the billing provider/supplier. The treating physician, another clinician, provider, or supplier should submit the requested documentation. However, because the provider selected for review is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, RAC and UPIC.   The CERT reviewer shall request medical record documentation from the referring provider as submitted/identified by National Provider Identifier/Unique Physician Identification Number on the claim when such information is not sent in by the billing supplier/provider initially and after a request for additional documentation fails to produce medical documentati on necessary to support the service billed and supported by the Local and National Coverage Determinations.  The MAC, UPIC and RAC have the discretion to send a separate ADR to third-  party entities involved in the beneficiarys care. They shall not solici t documentation from a third party unless they first or simultaneously solicit the same information from the billing provider or supplier. The following requirements also apply:    The MACs, UPICs and RACs shall notify the third party and the billing provide r or supplier that they have 30 calendar days to respond for a prepayment review or 45 calendar days for a postpayment review for MACs and RACs and 30 calendar days for  UPICs.    For prepayment review, the MACs and UPICs shall pend the claim for 45 calendar days. This 45 day time period may run concurrently as the 45 days that the billing provider or supplier has to respond to the ADR  letter;    The MACs and UPICs have the discretion to issue as many reminder notices as they deem appropriate to the third party via email, letter or phone  call prior to the 30th or 45th calendar day, as discussed  above;    When information is requested from both the billing provider or supplier and a third party and a response is received from one or both that fails to support the medical necessity of the service, the MACs and UPICs shall deny the claim, in full or in part, using the appropriate denial code. Contractors shall  count these denials as medical record  reviews.    Contractors shall include language in the denial notice remi nding providers that beneficiaries cannot be held liable for these denials unless they received proper liability notification before services were rendered, as detailed in CMS Pub.100-  04, Medicare Claims Processing Manual, chapter  30.   Refer to3.2.3.7 for ADR to ordering providers for lab services.     3.2.3.4 - Additional Documentation Request Required and Optional Elements  (Rev. 557, Issued: 11- 26-14, Effective: 12 -29-14, Implementation: 12- 29-14)  This section applies to Medicare Administrative Contractors ( MAC), Recovery Auditors, Comprehensive Error Rate Testing ( CERT), and Supplemental Medical Review Contractors ( SMRC), as indicated.    The MAC shall use discretion to ensure that the amount of medical documentation requested does not negatively impact the providers ability to provide care.    The Recovery Auditors shall issue Additional Documentation Requests (ADR) in accordance with limits established by their Contracting Officers Representative (COR) for each calendar year.    The MACs, CERT, SMRCs, and Recovery Auditors, shall request records related to the claim(s) being reviewed and have the discretion to collect documentation related to the beneficiarys condition before and after a service.    The MACs, Recovery Auditors, and SMRCs have the discretion to issue as many reminder notices as they deem appropriate.  Reminder notices can  be issued via email, letter, or phone call.    The CERT shall issue reminder notices in accordance with its SOW.    The MACs, Recovery Auditors, and S MRCs shall not target their ADRs to providers based solely on the providers electronic health record status or chosen method of submitting records.  When requesting documentation for postpayment medical review, the MACs, CERT, SMRCs and Recovery Auditors shall use the unified postpayment ADR letter format. Contractors shall maintain the format of the letter, but have the discretion to insert case -specific information. In other words, contractors shall not change the order of the sections on the letter, but  should modify the text underneath each section to provide detailed information and accurately reflect the information specific to the subject of the letter. The detailed text in the Exhibit 46 templates serves only to provide an example of what types of information belong under each section heading. The templates show the format and order contractors shall use when constructing postpayment ADR letters.   If any of the elements are lengthy, contractors have the discretion to utilize an attachment to provide  the details. If a contractor does not have attachments, but has supplementary information to provide in the text of the letter, the contractor should insert the text beneath the section title Attachments / Supplementary Information).   The MACs, CERT, S MRCs and Recovery Auditors shall include the following elements in their ADRs and shall use the appropriate templates provided in Exhibit 46:   A. Introductory Paragraph   CMS as the government agency making the request;   The program making the request (e.g. the MAC program, the SMRC program, the Recovery Audit Program, the CERT program); and  The regulations and/or laws that apply to the request.  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.