Medical Review 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.
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.
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
Medicare Area
P.O. Box 1602
Omaha, NE 68101
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 sheet 
to the top of each set of medical records to expedite handling.
Select this link for the full Documentation Guidelines file.
Page Last Updated: Thursday, 18-Mar-2010 05:48:14 CDT
