February 6, 2012
Furnishing Documentation to Support Medicare Services
For any item to be covered by Medicare, the patient's medical record must contain sufficient information about the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information, as applicable, such as duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature, and results, past experience with related items, etc. For selected claims, the MAC Contractor may request this information from you in order to verify that Medicare coverage criteria have been met.
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits disclosure of protected health information without beneficiary authorization when necessary to carry out treatment, payment, or health care operations. The CERT and MAC Contractors perform health care operations as agents of the Centers for Medicare and Medicaid Services (CMS). Providing the requested documentation is in keeping with the HIPAA Privacy Rule.
Finally, your cooperation is a legal requirement as outlined in the Social Security Act, the law governing Medicare. Section 1842(p)(4) of the Act mandates that:
[i]n case of an item or service…ordered by a physician or a practitioner…but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.
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