(Medicare Program Integrity Manual)

The SMRC shall operate/maintain a public Web site that displays what types of issues are under review. For each area, the S MRC shall include a link to the relevant OIG/GAO or other reports available. In addition to the Web site, the SMRC shall notify providers about a service -specific review by sending an ADR. The SMRC shall state what additional documentation is needed from p roviders to make a claim determination in the ADR.   3.2.2.1 - Maintaining Provider Information  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  The term Medicare beneficiary identifier (Mbi) is a general term describing a bene ficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   This section applies to MAC.  A. Provider Tracking System  (PTS)  The MACs shall have a PTS in place to identify and track all individual providers currently under action plans to correct identified problems, such, as not reasonable and necessary, incorrect coding, and inappropriate billing. MACs shall use the provider tracking system (PTS) to coordinate contacts with providers such as MR notifications, telephone calls directly related to probe reviews, and referrals to POE. The MACs shall ensure that if a provider is to be contacted as a result of more than one problem, redundant contacts are minimized. The MACs shall also coordinate corrective action information with the UPICs to ensure contacts are not in conflict with benefit integrity related activities. The MAC PTS shall contain the date a provider is put on a provider - specific edit. The MAC shall reassess all providers on provider -specific prepayment or postpayment review on a quarterly basis to determine whether the behavior has improved. The MAC shall note the results of these quarterly assessments in the PTS. If the behavior has improved sufficiently and the edit was turned off, note that date as well in the PTS. When a MAC becomes aware that the provider has appealed a medical review determination to an Administrative Law Judge (ALJ), the MAC should send a letter  to the ALJ and describe the information in the PTS to demonstrate the corrective actions that have been taken by the MAC.  B. Recovery Auditor Case  Files  The Recovery Auditor shall maintain case files following the guidelines in the Recovery Auditor SOW.  C. Provider Addresses   This section applies to MACs, CERT, and Recovery Auditors, as indicated.   The MACs, CERT and Recovery Auditors shall mail the ADR to the best known address for the provider. MACs are encouraged to indicate the procedure a provider can f ollow to update address information in their ADRs and on their Web sites. If a provider wishes to have ADRs sent to one address but demand letters sent to a different address, MACs are encouraged to accommodate this  request.   Note: Providers and suppliers must complete and submit a Medicare enrollment application (either the paper CMS -855 or a submission via Internet -based Provider Enrollment, Chain & Ownership [PECOS] to change existing information in the Medicare enrollment record.)   D. When the Provider or Supplier No Longer Occupies a Physical  Address   This section applies to MACs and UPICs, as indicated.   When the MACs and UPICs become aware that the provider or supplier no longer occupies a physical address, any future correspondence shall reference only the claim control numbers and not list the individual beneficiary data (e.g., names and Medicare beneficiary identifiers). This process is contingent on current automated system limits.   The following are situations where the MAC and UPIC can assume the pr ovider or supplier no longer occupies the last known location. This list is not exhaustive and the MACs and UPICs should use other means to confirm addresses, at their discretion.    The MAC and UPIC receive mail that has been returned by the post office indicating no known address;    An onsite visit has confirmed the address is vacant or is occupied by another occupant;  or,   A beneficiary complaint(s) is on record stating the provider or supplier is  no longer at the address and follow up confirms the  complaint.   In the above situations, correspondence from the MACs and UPICs shall only contain the claim control number and advise the provider or supplier to contact them for a list of the specific claims associated with the overpayment. This process wi ll prevent the potential compromise of Medicare beneficiary names and/or Medicare beneficiary identifiers being sent to an abandoned address (or a location with a new occupant). If the letter is returned from the post office, maintain the notification on f ile for evidence.   3.2.3 - Requesting Additional Documentation During Prepayment and Postpayment Review (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, CERT, RACs, and UPICs, as indicated.   A. General   In certain circumstances, the MACs, CERT, RACs, and UPICs may not be able to make a determination on a claim 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 a dditional documentation request (ADR). The term ADR refers to all documentation requests associated with prepayment review and postpayment review. MACs, CERT, RACs, and UPICs have the discretion to collect documentation related to the beneficiarys conditi on before and after a service in order to get a more complete picture of the beneficiarys clinical condition. The MAC, RAC, and UPIC shall not deny other claims submitted before or after the claim in question unless appropriate consideration is given to t he actual additional claims and associated documentation. The CERT contractor shall solicit documentation in those circumstances in accordance with its Statement of Work  (SOW).   The term additional documentation refers to medical documentation and other documents such as supplier/lab/ambulance notes and includes:    Clinical evaluations, physician evaluations, consultations, progress notes, physicians office records, hospital records, nursing home records, home health agency records, records from other hea lthcare professionals and test reports. This documentation is maintained by the physician and/or  provider.   Supplier/lab/ambulance notes include all documents that are submitted by suppliers, labs, and ambulance companies in support of the claim (e.g., Cer tificates  of Medical Necessity, supplier records of a home assessment for a power  wheelchair).    Other documents include any records needed from a biller in order to conduct  a review and reach a conclusion about the claim.   NOTE: Reviewers shall consider documentation in accordance with other sections of this manual.   The MAC and UPIC have the discretion to deny other related claims submitted before or after the claim in question, subject to CMS approval as described below. If documentation associated with one claim can be used to validate another claim, those claims may be considered related. Approved examples of related claims that may be denied as related are in the following situations:    When the Part A Inpatient surgical claim is denied as not reasonable and necessary, the MAC may recoup the surgeon's Part B services. For services where the patients history and physical (H&P), physician progress notes or other hospital  record documentation does not support the medical necessity for performing the  procedure, postpayment recoupment may occur for the performing physicians Part B  service.    Reserved for future approved related claim review situations. The MAC  shall report to their BFL and COR prior to initiating denial of related claims  situations.   The MAC and UPIC shall await CMS approval prior to initiating requested related claim(s) review. Upon CMS approval, the MAC shall post the intent to conduct related claim review(s) to their Web site within 1 month prior to initiation of th e approved related claim review(s). The MAC shall inform CMS of the implementation date of the related claim(s) review 1 month prior to the implementation date.   If related claims are denied automatically, MACs shall count these denials as automated review. If the related claims are denied after manual intervention, MACs shall count these denials as non- medical record review.   The RAC shall utilize the review approval process as outlined in their SOW when performing reviews of related claims.   The MAC, RAC, and UPIC are not required to request additional documentation for the related claims before issuing a denial for the related claims.   Contactors shall process appeals of the related claim(s) separately.   B. Authority to Collect Medical Documentation   Contractors are authorized to collect medical documentation by the Social Security Act. Section 1833(e) states No payment shall be made to any provider of services or other person under this part unless there has been 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. Section 1815(a) states 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.   The OMB P aperwork Reduction Act collection number for prepayment medical review is 0938- 0969. MACs shall use this number on every additional documentation request or any other type of written request for additional documentation for prepayment medical review. It can be in the header, footer or body of the document. CMS suggests the information read OMB #: 0938- 0969 or OMB Control #: 0938- 0969. Postpayment medical review does not require an OMB control number.  C. PWK (Paperwork)  Modifier  MAC medical review departments are only required to review unsolicited documentation when the claim suspends for a medical review edit/audit. MACs shall not send an ADR request for a claim with a PWK modifier until after review of the PWK unsolicited documentation or the waiting days have elapsed without receipt of documentation.  MACs shall allow 7 calendar waiting days (from the date of receipt of the claim) for additional unsolicited documentation to be submitted or 10 calendar waiting days for the unsolicited documentation to be mailed. Contractors serving island territories shall have the flexibility to adjust waiting days as is necessary. CMS expects that any adjustment from the core 7/10 days will be discussed with and approved by your contracting officer prior to  implementation. When the documentation is received, the contractor has 30 calendar days to make a determination on the claim. If the contractor cannot make a determination on the claim after reviewing the unsolicited documentation submitted, they shall request additional documentation using their normal business procedures for ADR that are outlined in Chapter 3 of the Program Integrity Manual.  3.2.3.1 - Additional Documentation Requests (ADR)  (Rev.933; Issued: 01-10- 20; Effective: 02 - 03- 20; Implementati on: 01-06- 20)  This section applies to MACs, Recovery Auditors, CERT and UPICs , as indicated.   The MACs, CERT, Recovery Auditors, and UPICs  shall specify in the ADR only those individual pieces of documentation needed to make a determination. When reviewing documentation, the reviewer shall give appropriate consideration to all documentation that is provided in accordance with other sections of this manual.  The MACs and the RACs shall also support soliciting documentation from the provider or supplier via Electronic Submission of Medical Documentation (esMD). The contractors shall send an Electronic Medical Documentation Request (eMDR) via es MD to those providers/suppliers that have registered to receive the request electronically. The contractors are encouraged to explore other ways to send eMDRs electronically (For example, using direct exchange, clearinghouses, state Health Information Exchange (HIEs)).   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)