Medical Review Documentation Check List

When submitting requested medical records for Medical Review or the CERT contractor please remember:

  • All documentation must be legible
    • For clarity, you may need to submit transcriptions of the original preexisting medical record documentation
  • All Documentation and orders must have a legible and valid signature
    • If your signature is difficult to read please send a signature log or attestation statement to confirm the author
    • Electronic signatures must be authenticated by the author
    • If your written signature is missing or there is not a authenticated electronic signature on the medical records, an attestation statement must also be submitted to confirm the author of the note
    • If a signature is missing from an order, claims reviewers will disregard the order during the review of the claim
    • The attestation statement must be signed and dated by the author of the medical record entry with the appropriate beneficiary information
  • All Documentation required to support medical necessity and substantiate the provider’s intent for that procedure must be included
    • If documentation is requested for a procedure or diagnostic test please be sure to also submit a signed order or the visit notes supporting the intent for these service(s)
    • Check for Medicare Policy or LCDs which relate to the service(s) billed and be sure to include all documentation required by the policy to support the medical necessity. This information can be found under the Policy tab on the top navigation bar.
    • A few requests may require you to contact other providers, agencies, and/or facilities to obtain the requested medical records. It is the provider's responsibility to obtain this information.

If an attestation statement is required, please review the Attestation Statement example within the Forms portion of the website, to determine what information an attestation should contain.

While this list is not all-inclusive, following these three basic checks will help ensure avoiding many unnecessary denials for claims. For additional tips on signatures and/or tips on how to document services appropriately, please review the articles listed under the Current Topics heading on the Medical Review page.

Signature Requirements

Signature Requirements can be found within the CERT portion of the website.

Page Last Updated: Wednesday, 05-Oct-2011 12:36:58 CDT