WPS Medical Review Process

WPS Medical Review follows the Centers for Medicare & Medicaid Services (CMS) Progressive Corrective Action (PCA) process. WPS conducts Probe reviews on providers whose billing characteristics are different from that of their like peers as identified through data analysis. A certified letter is sent to the provider requesting medical records and gives detailed instructions to follow when submitting the supporting medical documentation.

A WPS Senior Nurse Analyst will contact the provider's administration to answer any questions and act as a facilitator during the Probe. After the Probe review is completed, the provider may be released from PCA, or a Targeted Medical Review (TMR) will be initiated based on the Probe results. The assigned Senior Nurse Analyst is available to offer feedback, education, and assistance with the TMR process.

Providers must submit all documentation requested by the Fiscal Intermediary (FI) or Medicare Administrative Contractor (MAC) at the expense of the provider. If a copy service is used, they need to be instructed not to bill WPS for the copying and mailing expenses. If the requested documentation is not submitted or not submitted timely, a denial for breach of Medicare contract is issued and a denial code of 56900 is implemented. The provider must submit the requested documentation within 12 months of the original request for an initial determination to be made and afforded appeal rights if denied. Only claims that have been reviewed and denied for medical necessity are afforded appeal rights.

What can you do to assist in the claim review process?

• Have internal processes in place for the rapid response to record request letters.
• Build cooperative relationships with referring providers for timely receipt of requested documentation.
• Submit documentation within the timelines to avoid unnecessary denials.
• Utilize your Senior Nurse Analyst for their feedback and knowledge of documentation requirements.
• Know your Medicare regulation for benefit coverage.

Page Last Updated: Friday, 06-Nov-2009 14:04:41 CST