Novice Know How - The Importance of Submitting Requested Medical Records
When a provider receives a written request from WPS Medicare for documentation to support the medical necessity and/or level of a service billed, it is the provider's responsibility to supply the requested information within 45 days. It is imperative that requests for additional medical records from either WPS Medicare or the CERT Document Contractor (CDC) for CERT (Comprehensive Error Rate Testing) be responded to in a timely manner. Services for which the records are not received within the timeframe designated in the Medical Record Request Letter will be denied. In addition, for a postpay review, an overpayment will be assessed.
Providers need to keep their addresses and phone numbers current through timely notification to WPS Medicare Provider Enrollment. Delays resulting from having to deliver the Medical Record Request Letter to a forwarding address will significantly decrease the timeframe for submitting the records. The Provider Enrollment Hotline for Illinois, Michigan, and Wisconsin is 877-908-8476 and for Minnesota 866-564-0315.
Providers must submit all documentation necessary to determine the medical necessity for each billed service and to substantiate the appropriate use of each billed procedure code. Documentation may include - but is not limited to - treatment notes for the date of service, physician's orders, and plan of care. Also, tests, radiology, and medical procedure reports/findings may need to be submitted, if not specifically addressed in the documentation. To obtain the requested medical records, the billing provider may need to contact:
- Other agencies
- Other providers
- Other facilities
Beneficiaries authorize the release of medical or other necessary information by signing either the CMS 1500 claim form or the "Statement to Permit Payment of Medicare Benefits to Provider" release form. The Health Insurance Portability and Accountability Act (HIPAA) does not prohibit the release of individual beneficiary medical records to the carrier or the Program Safeguard Contractor for medical review of billed services.
It is the goal of WPS Medicare to ensure that providers are properly reimbursed for the medically necessary services they perform. Therefore, when WPS Medicare or a PSC (such as CERT) request documentation supporting billed services, medical records must be submitted in a timely manner.
