Medical Review - JF Part B

Q1: Why does a radiologist have to submit progress reports to support medical necessity from the ordering/referring provider? We do not have these.
A1: Per 42 Code of Federal Regulations (CFR) 424.5(a)(6) "(6). The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment." eCFR :: 42 CFR 424.5 -- Basic conditions. Also, CMS Internet Only Manual (IOM), Publication 100-04, Medicare Program Integrity Manual, Chapter 3, section 3.2.3.3 states "Unless otherwise specified, the MAC, RAC and UPIC shall request information from the billing provider/supplier. The treating physician, another clinician, provider, or supplier should submit the requested documentation. However, because the provider selected for review is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, RAC and UPIC."

Q2: For a Targeted Probe and Educate (TPE) review what type of documentation should I submit?
A2: Generally, we request that you send any and all pertinent documentation to the date of service requested to establish medical necessity for the visit. This includes but is not limited to labs ordered and reviewed on the date of service, x-rays ordered and reviewed on the day of service, patient history and exam, the signed progress note from the provider, vital signs records, nursing notes, and any other pertinent documentation. Review Documentation Requirements this site gives information on what to send based on procedure code or service.

Q3: For a Targeted Probe and Educate review how will I receive the additional documentation request (ADR) letters?
A3: When the Current Procedural Terminology (CPT) code on review is billed, the Multi-Carrier System (MCS) that is utilized for Medicare claims will automatically create an Additional Documentation Request Letter (ADR) and it will be mailed to you using the Medical Records Correspondence Address (MRCA) address listed in MCS. If this address is not correct, the correct address will need to be updated via PECOS Medicare Enrollment. A round of TPE review consists of 20-40 claims, so you can expect 20-40 individual letters in the mail. The ADR letter will have the Internal Control Number (ICN), beneficiary name, date of service, a list of possible documentation to submit, a due date and how to submit documentation. Each ADR letter sent will have a date for when the documentation is due to be submitted to Noridian, as a provider, you have 45 days to submit documentation. You can also see the ADR letters on the Noridian Medicare Portal If you need help with gaining access to your NMP account, you can contact user security at 877-908-8431.