Medical Review - JE Part B
Medical Review Frequently Asked Questions (FAQs)
Q1. We have had claims selected for medical review. However, we do not have access to the mail at the address to which the additional documentation request (ADR) letters are sent to. Is there a way to have the ADR letters send to us directly?
A1. Yes. Beginning April 4, 2022, you can designate a Medical Record Correspondence Address (MRCA). If the MRCA is active, it will be used for all medical review correspondence/letters. The system will default to the existing provider address if an active MRCA is not available or if a development letter does not involve a medical review request. To update the MRCA utilize the CMS-855I form (Section 2E) for individual physician and non-physician practitioners or the CMS-855B form (Section 2A4) for groups and organizations. The forms are located at: Enrollment Forms
Q2: I haven’t heard back yet about the determination on a prior authorization request I recently submitted; how can I check the status?
A2: After receipt of all relevant documentation, the MAC will make a determination postmark the letter of their decision to the ambulance supplier and the beneficiary within 10 business days for both initial and resubmitted requests. Prior authorization should ideally be requested prior to rendering transports. Claims for the first three round trips are permitted to be billed without prior authorization to allow time to submit the prior authorization request and obtain approval. If you have not received a determination in the mail within the allotted timeframe (adding mail time to the 10 business days), you may email email@example.com. Please ensure to only send one request at a time per beneficiary and wait until completion of medical review and a decision is rendered before potentially resubmitting a request.
Q3: What origin and destination information do I need to submit on a prior authorization request?
A3: Sufficient information on the origin and destination of the transports to corroborate the specific locations, such as the full physical addresses for both the origin and destination.
Q4: What documentation do I need to submit to support medical necessity of RSNAT services?
A4: The beneficiary's condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. Refer to CFR 410.40(e) for medical necessity criteria. Medicare covers medically necessary nonemergency, scheduled, repetitive ambulance services if the ambulance provider or supplier, before furnishing the service to the beneficiary, obtains a physician certification statement (PCS) dated no earlier than 60 days before the date the service is furnished. In all cases, the provider or supplier must keep appropriate documentation on file and, upon request, present it to the contractor. The presence of the signed PCS does not alone demonstrate that the ambulance transport was medically necessary. All other program criteria must be met in order for payment to be made. Documentation from the medical record to corroborate the PCS and the medical necessity of the transports, and any other relevant document as deemed necessary by the MAC to process the prior authorization.
Last Updated Mon, 27 Jun 2022 16:38:51 +0000