Submitting Medical Records

Post-pay probe review

When a claim is selected for a post-pay medical review, place a copy of probe letter on the top of each set of documentation submitted. This will ensure that the documentation is delivered to the proper Senior Nurse Coordinator requesting the information. It is not acceptable to place a copy of the Medicare Medical Review Cover Sheet on the top of a Post-Pay Probe review. These cover sheets are to be utilized for pre-pay reviews only.

In order to expedite the process, by which we document medical records as received, we recommend that you send the information to:

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

Pre-pay medical review

When a claim submitted is selected for pre-pay medical review we recommend that you return the requested medical records with one of the following as the cover sheet:

To identify claims that have been selected for medical review, providers should access Status/Location codes SB6000, SB6001 or SB6099. FISS DDE providers can access the Inquiries Menu (#1) and Claims Sub-Menu (#12).

To identify claims, for which medical documentation has been requested and received, providers should access Status/Location code SMRDOC. FISS DDE providers can access the Inquiries Menu (#1) and Claims Sub-Menu (#12).

You will not be able to update claims while they are in any of the locations listed above.

Claims awaiting medical documentation will remain pending in our system for 45 days. On the 46th day, if the documentation needed to make a medical determination is not received, the claim will be denied as records not received timely. You have the right to submit a request for a reopen. Reopens should be submitted to Medical Review with a cover letter indicating it is a reopen.

In order to expedite the process, by which we document medical records as received, we recommend that you send the information to the following address:

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

The 45-day clock starts with the date the claim edits for medical review, and continues until the records are date stamped as received at WPS - Medicare. Please keep this in mind and allow enough mailing time to ensure that the records are received before the 45th day. We recommend you consult with your local Post Office to determine what your standard mail time is. This should be taken in to consideration when determining how much time you have to get records submitted to our office.

Page Last Updated: Thursday, 15-Dec-2011 13:58:03 CST