Medical Review - JF Part B
Medical Review Frequently Asked Questions (FAQs)
Q1: How can I ensure I receive my Medical Review Additional Documentation Requests (ADRs) and review notifications?
A1: The Medical Review Correspondence Address (MRCA) is a designated mailing address maintained in Medicare systems, primarily for group PTANs, for the receipt of Medical Review correspondence. When an active MRCA address is on file, Additional Documentation Requests (ADRs) are mailed to this address, as it represents the provider's preferred location for audit and review-related communications.
Medical Review staff are unable to update the address used for ADR correspondence. If you would like to update the MRCA address, please contact Provider Enrollment or submit the appropriate enrollment update form available on the Medicare Enrollment Forms webpage.
Educational correspondence from Noridian, such as notification and findings letters, is sent to the rendering provider address associated with Medicare records. If you have questions regarding the address used for educational correspondence or would like to request a different eligible address, please contact the case manager.
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Q2: What documentation should I submit when responding to a Targeted Probe and Educate (TPE) review?
A2: Providers should submit all documentation necessary to support medical necessity and the services billed for the requested date(s) of service. This requested documentation is requested in the ADR and may include progress notes, orders, diagnostic reports, physician documentation, treatment records, and any other records used in making clinical decisions. Complete documentation allows for an accurate review and may reduce delays in claim processing. Providers can also use the Noridian website to locate the Additional Documentation Requests by selecting the service on review.
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Q3: Why am I required to obtain and submit documentation from the ordering or referring provider?
A3: Per Internet Only Manual (IOM) Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.3;
“Unless otherwise specified, the MAC, CERT, SMRC, UPIC and RAC shall request information from the billing provider/supplier. The treating physician or other clinicians should provide any requested or relevant documentation. However, because the billing provider/supplier selected for review is the one whose payment is at risk, it is this billing provider/supplier who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, SMRC, UPIC and RAC”
Medicare regulations require the billing provider to furnish sufficient documentation to establish coverage and payment. While the ordering or referring provider may have created portions of the medical record, the billing provider is ultimately responsible for obtaining and submitting all documentation necessary to support medical necessity when records are requested during a review.
