Corporate

June 25, 2013 - Updated 10.28.16

Medical Record Requests: Keys to Success

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:

  • Comprehensive Error Rate Testing (CERT) program
  • "Additional Documentation Request" letters (ADR letters): more information is required before the Medicare contractor can process the claim. Examples:
    • 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 Auditor (RA)

Keys to success:

  • Send all relevant documentation, but only the relevant documentation.
  • Send it on time
  • Send it to the right entity / address or fax number
  • Include a copy of the request letter with your submission

Note: Your facility may have designated a single point of contact or coordinator for medical record requests from Medicare contractors.

We recommend that you check with your compliance officer or manager before submitting records or transferring the request to another department. Your office or facility may have specific internal guidelines; CGS offers this guidance to supplement your own processes and procedures.

Reason for Request Last Date to Submit Records Return the Records To
Review of medical records, through the CERT program

Initial Requests – Provider has 75 days from the date on the letter

Additional Documentation Requests (tech stops)provider has 15 Days
Letter 3 is sent at 45 days
Letter 4 sent at 60 day

Day 76 claim will be counted as error
CERT Documentation Center

Fax records with CID and bar code sheet to (240) 568-6222.

Physical address:
CERT Documentation Center
Attn CID # ________
1510 East Parham Road
Henrico, VA 23228
Fax:  240-568-6222
Customer Service:  443-663-2699
Toll Free:  888-779-7477
E-mail: certmail@admedcorp.com
 
More information is required before Medicare can process the claim.

The claim has not yet been paid. This is called an additional documentation request letter (ADR).
30 days from the date on the letter

CGS

Address can be found in the letter

 
Review of records for a new physician or practitioner before the claim is paid 30 days from the date on the letter


CGS

Address can be found in the letter

 
Review of claims by the Recovery Auditor (RA) 45 days from the date on the letter Electronically, via the Electronic Submission of Medical Documentation (esMD) process or in a CD or DVD: refer to the document "Medical Record Submission Instructions: Medicare's CGI RAC Region BExternal PDF" for complete instructions

By fax: 1.216.902.3860

By mail:
CGI Federal Inc.
Attn: RACB Imaging Dept
1001 Lakeside Ave., Suite 800
Cleveland, OH 44114

 
Review of an established physician or practitioner before the claim is paid 30 days from the date on the letter CGS

The address will be listed in the body of the letter.
 
Review of an established physician or practitioner after the claim was paid 30 days from the date on the letter CGS

The address will be listed in the body of the letter.
 
Investigation of a complaint alleging possible fraud or abuse May vary (refer to specific letter for details) Cahaba Safeguard Administrators, LLC The address will be listed in the body of the letter.

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 and Management service, or E/M service) include documentation for that encounter along with the following:
    • If the physician/NPP's note refers to an earlier encounter date (such as a prior history or list of prescription medications), include copies of the earlier note as well as information pertinent to the date requested.
    • If the physician/NPP's note refers to results of a lab or other diagnostic test, include the test results with the requested information.
    • If 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.
  • If the physician or practitioner's signature is not legible, provide a signature log with the practitioner's typed/printed name and handwritten signatures for authentication of illegible signature, or provide a signature attestation form (CGS has an example formPDF).
  • If the service was provided based on an order, provide documentation of the order. This is especially important for clinical laboratory tests and diagnostic services, including x-rays and EKGs. Include with the order the office/progress note documenting the medical necessity of the service.
  • If the physician or practitioner uses abbreviations that are not common, provide a key.
  • If the patient signed an Advance Beneficiary Notice of Non-coverage (ABN), include a copy with the requested records.
  • If the service is the physician's interpretation of a diagnostic test (e.g., 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.
  • If the documentation resides with a third party (i.e. hospital, SNF) it is your responsibility to obtain copies for submission.

Other Tips:

  • Each letter from Medicare requesting medical records will be on CMS letterhead or CGS 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
  • When responding to a CERT request always write the Claim Identifier (CID) number on the medical record. The CID number can be found on your request letter.
  • 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 CGS 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:
    • 615.782.4591
  • If the request is from Cahaba Safeguard Administrators, call the specific telephone number listed in the letter.

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