Documentation Requests: How, Who and When to Send - JF Part A
Documentation Requests: How, Who and When to Send
As part of the Medical Review process, Noridian requests medical records for some services prior to completing claim processing. A good rule of thumb is to send records which support the service and diagnosis(es) submitted on the claim as well as the medical necessity for the services.
Letters are sent to the Correspondence address on file in PECOS (Provider Enrollment, Chain and Ownership System) online enrollment site.
Medical records could also be requested from other entities outside of Noridian.
Pre-payment: Review of claims prior to payment being received. Prepayment reviews result in an initial determination.
Post-payment: Review of claims after payment has been determined. Post-payment reviews may result in either no change to the initial determination or a revised determination, indicating an underpayment or overpayment.
| Request From | Days to Respond (from date on letter) | Response Delivery Options | Additional Information |
|---|---|---|---|
| Noridian Pre-pay medical review claims and Targeted Probe and Educate (TPE) | 45 | Noridian Medicare Portal Regular mail: Refer to letter Fax:
Electronically: CD, DVD, USB, or esMD | |
| Noridian Post-pay - Medical Review | 45 | Regular mail: Refer to letter Fax: 701-277-6977 Electronically: CD, DVD, USB, or esMD | |
| CERT (Comprehensive Error Rate Testing) NCI Information Systems | 45
| Regular mail: CERT Documentation Center Fax: 804-261-8100 (use barcode cover sheet) Electronically: CD, esMD, encrypted email | |
| QIO (Quality Improvement Organization) Review link for state contractor | Determined by request letter | Refer to letter | |
| RAC (Recovery Audit Contractor) Cotiviti | 30 | Cotiviti's Secure Provider Portal Regular mail: Cotiviti RAC 4 Fax:
esMD | |
| SMRC (Supplemental Medical Review Contractor) Noridian SMRC | 45 | Regular mail: Refer to letter Fax: 701-277-6834 Electronically: CD, DVD, USB, or esMD | |
| UPIC (Unified Program Integrity Contractor) Qlarant | 45 | Regular mail: Refer to letter Electronically: CD, esMD, Kite Works |
CMS Resources
- Electronic Submission of Medical Documentation (esMD) - esMD for Medicare Providers and Suppliers
- CMS Complying With Medical Record Documentation Requirements Fact Sheet
- CMS Medical Record Maintenance & Access Requirements Fact Sheet
- CMS Medical Review and Education
- MLN Medicare Overpayments Fact Sheet
- CMS Internet Only Manual (IOM), Publication 100-06, Medicare Financial Management Manual, Chapter 3, Section 200 - Section 935 - Limitation on Recoupment Overpayments
Office of Inspector General (OIG) record requests - Refer to letter for details
