Documentation Guidelines

The Centers for Medicare & Medicaid Services (CMS) requires us to review a sample of claims submitted to verify services billed are covered and are reasonable and necessary. We will notify you if a claim has been selected for medical review. You will receive a letter requesting documentation and you may access the request for documentation via the remote system.

Medicare requires that medical record entries for services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamp signatures are not acceptable. Beneficiary identification, date of service, and provider of the service should be clearly identified on the submitted documentation.

The documentation you submit in response to this request should comply with these requirements. This may require you to contact the hospital or other facility where you provided the service and obtain your signed progress notes, plan of care, discharge summary, etc. If you question the legibility of your signature, you may submit an attestation statement in your ADR response.

If the signature requirements are not met, the reviewer will conduct the review without considering the documentation with the missing or illegible signature. This could lead the reviewer to determine that the medical necessity for the service billed has not been substantiated.

Following is an alphabetical listing of the services for which we most often request documentation. For each of the services listed, we provide some recommendations for the type of information and/or medical records to submit when we request it. In the event that all documentation is not submitted, a coverage decision will be made based upon the documentation submitted.

If you have questions regarding what type of information to send us, please refer to these guidelines. For example:

  • If our message states: PT-Send all Documentation to Support the Services Billed
  • Refer to the Therapy section of the attached guidelines for recommendations on the types of information to submit for our review.

For example, if our message states, "PT-Send all Documentation to Support the Services Billed," refer to the Therapy section of the attached guidelines for recommendations on the types of information to submit for our review.

In order to expedite the documentation of medical records received, we recommend that you send the medical records to the following address. If you send them to any other address or via certified mail, we cannot guarantee that they will arrive in our department timely.

WPS
Medicare Area
P.O. Box 8310
Omaha, NE 68108-0310

Note: Documentation should be submitted to our office no later than 30 days from the date of the request. If a response to our documentation request is not received within 45 days of the date of the request, the claim will be denied. Please be sure to attach either the hardcopy request letter or a remote cover sheetAdobe Portable Document formatto the top of each set of medical records to expedite handling.

Select this link for the full Documentation Guidelines file.

Page Last Updated: Monday, 07-Nov-2011 08:50:38 CST