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Prepay Medicare Review Part A
Documentation Requirements
Title XVIII of the Social Security Act, Section 1833(e) prohibits Medicare
payment for any claim which lacks the necessary information to process the
claim. Section 1862(a)(1)(A) of the Act allows coverage and payment for only
those services that are considered to be medically reasonable and necessary.
The "Program Integrity Manual", Chapter 3,
Section 3.11.1 states:
"For Medicare to consider coverage and payment for any service, the
information submitted by the provider or supplier……must be corroborated by
the documentation in the patient’s medical records that Medicare coverage
criteria have been met. This documentation must be maintained by the
physician and/or provider and available to the contractor on request".
Failure to submit requested documentation will result in complete or partial
denial of services.
Your documentation is the most important factor to success in getting a claim
paid. It must support the fact that whatever is billed was needed by the
patient, actually provided to the patient, and certified by the physician. If
the correct documentation is provided and it follows the policies (Local and CMS
Manual guidelines), the claim is likely to be allowed.
This web page has been specifically designed by Prepay Medical Review Part A
to assist providers with fulfilling documentation requirements to support the
services being billed and to provide a better understanding of the documentation
needed to adjudicate claims appropriately.
Direct links to documentation requirements for specific services that have
been or currently are under review are listed below:
Please note, these will be revised and updated as necessary.
There are other websites listed on the Medical Review web page that were
designed to provide a better understanding of Medical Review activities. Please
take the time to browse each of them to familiarize yourself with the probe
process, edit/audit process, Progressive Corrective Action (PCA Process), and
general documentation tips. Specialty web pages for Skilled Nursing Facilities
and Inpatient Rehabilitation Facilities have been created in response to
provider request in an effort to make the http://www.arkmedicare.com site more
user-friendly. Articles pertinent to these services will be posted when
appropriate but you will also find a direct link to the CMS Home Pages for SNF
and IRF by which you may access all aspects of these services at any time.
The goal of Pinnacle Business Solutions, Inc. as your Medicare Fiscal
Intermediary (FI) is "to pay claims right the first time". In so doing, delays
in your reimbursement will be prevented and we can work together to
protect the future of the Medicare Trust Fund.
You are urged to routinely view your state Medicare website for updates,
articles, advisories, seminars, events and policy information. All policy
retirements, drafts, and new policies are posted with an open comment period.
Please be advised that if a draft policy is posted and pertains to your area of
practice, it is to your benefit to review the policy and take advantage of the
opportunity to comment on line before it is finalized.
The focus of this FI is education and toward that end, multiple educational
tools are also posted on your web site in an effort to meet your needs. There
are web based training modules available and Part A issues are currently being
added to this site. As always, we are eager to receive your feedback. Your
comments and suggestions will help us to improve our overall service to you. |
