Top Provider Questions – Medical Review
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- How long does it take to review a probe/ADR request once CGS receives the records? Will a denial letter be sent if it is denied?
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When CGS receives requested documentation for prepayment review within 45 calendar days, we will take these steps within 30 calendar days of receiving the requested documentation:
- Make and document the review determination and
- Enter the decision into the Fiscal Intermediary Share System (FISS).
We encourage you to monitor your Remittance Advice (RA) for claim determinations. In addition, if the review results in a partial or full claim denial, the reviewer will enter a brief comment on page 04 of the claim in DDE. Please reference Question and Answer #3 below for information on how to view claim comments through Direct Data Entry (DDE).
Reference:
Reviewed 12.16.2021
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- When will we see prepayment probe requests?
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Background: MACs initiate targeted provider-specific prepayment review only when there is the likelihood of a sustained or high level of payment error. MACs are encouraged to initiate targeted service-specific prepayment review to prevent improper payments for services identified by CERT or Recovery Auditors as problem areas. Reference: CMS Medicare Program Manual (Pub. 100-08) chapter 3, section 3.4
CGS announces prepayment probe reviews on our website under News and Publications.
Reviewed 12.16.2021
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- When medical necessity denials are issued by CGS after review of the medical record, it is difficult to determine the details around the denial from our Remittance Advice (RA). The remit only states "medical necessity." We have attempted to contact the CGS call center for details, but are not always able to get the clarification we need.
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When CGS issues a medical review denial, the denial reason code assigned to the claim/line item will begin with a '5' and offer a general explanation of the denial reason.
In addition, the reviewer enters a brief explanation in the Remarks section on page 04 of the claim.
For additional information, please reference the DDE User Manual.
Reviewed 12.16.2021
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- We have a question about prepayment reviews. If we determine the documentation in our chart does not meet criteria for inpatient status, should we just send the chart or just bill the outpatient services?
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If an inpatient claim was submitted for payment, you should submit the medical records to avoid a claim denial for non-receipt of records (reason code 56900). Once CGS receives your records, we will complete our review and adjudicate the claim. If the review results in a claim denial, and you disagree with the decision, you may request a redetermination (first level of appeal). If you agree with the decision, you may request payment for certain inpatient Part B hospital services as outlined in the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 4, section 240.1.
If a fully provider liable claim was submitted, it should not suspend for prepay review; however, if it does, respond to the Additional Documentation Request (ADR) and indicate the claim was billed as provider liable. CGS will then release the claim to process. Once the no-pay claim processes, you may then submit the inpatient Part B hospital services claim.
Reviewed 12.16.2021
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- We sent six sets of records in responses to Additional Documentation Requests (ADRs) from CGS, and it appears that you lost one set. At this point, how do we reopen the claim?
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We apologize if a record was not received, lost or misplaced. It is important to note that CGS conducts a separate and independent review of each claim. As a result, you should not send one set of medical records to support multiple dates of service selected for medical review. Each date of service is a stand-alone review. Submit the medical record appropriate for each date of service. You may send more than one ADR response in a single envelope; however, we strongly recommend that you separate each response with a copy of the ADR or the Direct Data Entry (DDE) screen print of the ADR attached to the front of each record. Make sure information submitted is for the appropriate beneficiary and dates of service.
Reminders for submitting documentation to CGS:
- Send the medical records in secure packaging to ensure the security of medical records.
- If you are responding to more than one date of service for the same beneficiary, send a separate response for each request. Include a manifest or list identifying each ADR response sent.
- Attach a copy of the ADR request to each individual claim.
- Use one staple or elastic band per record to attach the documentation and ADR together. Do not use paper clips, as they can become dislodged.
- Do not punch holes in medical records, as this may obscure or remove valuable information.
- Return the medical records to the address listed on the ADR.
- If CGS does not receive your response within the specified timeframe (45 calendar days), we will deny the service as not reasonable and necessary based on lack of documentation.
- If a claim is denied for non-receipt of records (reason code 56900), you may request a reopening. Complete the Redetermination Request Form (hard copy or via the myCGS portal) and indicate “56900 Reopening” (and any other necessary comments) in the Reason/Rationale section. The request will be forwarded to the Medical Review department to be processed as an MR reopening.
Reviewed 12.16.2021
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- Our claim denied for 56900. What do we do?
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You have 45 calendar days from the date on the ADR letter to submit medical records. If CGS does not receive the records by day 46, the claim is denied for non-receipt of records (Reason Code 56900). You have 125 days from the date on the remittance advice to submit the requested documents to the Medical Review Department. If records are received within the 125 day time-frame, Medical Review (MR) will review, make a determination, and adjust the claim accordingly. If you are beyond the 125 day time-frame, you may request a redetermination (first level of appeal).
Reviewed 12.16.2021
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