Frequently Asked Questions

RevisedOctober 2rd, 2013

 

What's New!

 

CGI Federal

What is the contact information for RAC B?

What is the contract duration between CGI Federal and CMS?

Who are the Medicare Administrative Contractors (MACs), Fiscal Intermediaries (FIs) and Carriers for Region B?

Provider Outreach

How often will CGI Federal provide onsite provider outreach?

Will the outreach be done in person or via conferencing?

CGI Medicare RAC Region B Website

What is the website address for RAC Region B?

Provider Information, CGI Medicare RAC Region B Website

How do providers gain access to the Providers link on the CGI Medicare RAC Region B Website?

How does CGI Federal obtain RAC contact information for providers that is accessed on the CGI Medicare RAC Region B Website?

How can providers update their contact information?

How does the page functionality work?

How do I use the claim status function on the Providers link?

How will CGI Federal communicate important information to the provider community?

New Issues, Areas for Review

What areas does CGI Federal intend to request CMS approval for audit?

How will CGI Federal communicate new issues for review to state hospital associations?

On the CGI Medicare RAC Region B Website, under Issues and then under Claim Types, when you include the word “Physician”, are you referring to private practices as well as Hospital Physicians?

Auditing

How are claims selected for audit?

Who will be auditing my claim?

Will all audits be conducted at the facility or provider location?

If an onsite audit is scheduled, how many CGI Federal staff will be assigned to review at the provider site?

Where are CGI Federal auditors located?

What is done to protect confidential data during an audit?

What is the maximum number of CGI Federal staff that could be physically present at the provider site?

How often will CGI Federal conduct an onsite provider review?

If CGI Federal denies a hospital claim for services, will they also deny the physician claim for services?

What utilization criteria will CGI Federal be using to review for medical necessity?

Will the RAC review any other Medicare plans, such as Medicare Advantage?

Will CGI Federal accept physicians’ notes from their offices to support the request for services?

Underpayments

What is an underpayment?

How is it determined that an underpayment was identified?

What is the process when CGI Federal identifies an underpayment?

Why are medical records being requested for an underpayment?

When will CGI Federal reimburse providers for the payment of requested medical records sent for an underpayment?

When will I get my underpayment money returned from the Medicare Administrative Contractor/FI/Carrier?

Can I appeal an underpayment?

Can CGI Federal provide a draft timeline for underpayments so the providers can better understand the framework that CGI is utilizing?

Overpayments

What is an overpayment?

I received notice of an identified overpayment.  What does it mean?

How is it determined that an overpayment was identified?

What is the dollar limit for a denial determination on an overpayment?

What if I do not agree with the Review Results Letter?

Automated Review

What is an automated review?

Can I appeal on an automated review?

What procedure does CGI Federal plan to utilize to coordinate recoupments with the Medicare Administrative Contractor/FI/Carriers?

Semi-Automated Review

What is a semi-automated review?

Does the RAC still have 60 days to complete the review upon receipt of a medical record?

Will providers receive a letter with the results of the review?

Will providers still have the Discussion Period option for a semi-annual review?

Can I appeal on a semi-automated review?

Complex Review

What is a complex review?

Can I appeal a complex review?

Additional Documentation Limits (ADR)

What are Additional Documentation Limits?

How can I view our Additional Documentation Limits?

What if I disagree with the Additional Documentation Limits calculations?

Medical Records Request (ADR Requests)

How can a provider send requested medical records to CGI Federal?

If we submit more than one DVD, do the DVDs need to be labeled 1 of 3, 2 of 3, 3 of 3?

May we place all DVDs in one package and provide one copy of the CGI RAC B Additional Documentation Request Letter?

If I send records on a CD or DVD, do they need to be encrypted?

When CGI Federal requests the entire Medical Record, do we need to send the UB04?

How long does the provider have to send in the medical records?

What happens if the provider misses the deadline?

Will CGI Federal pay for all requested medical records or just certain types?

What is the amount that CGI Federal will pay for medical records?

Will CGI Federal pay for postage?

Do I need to send CGI Federal an invoice for postage?

If a hospital or provider utilizes an electronic medical record system, what documentation will they be required to provide to CGI Federal?

I never received an Additional Documentation Request Letter and now I have an Overpayment Demand Letter.  What do I do?

Pre-payment Therapy Reviews

Where do I mail medical records for pre-pay therapy reviews?

Review Results Letter

How will CGI Federal send the Review Results Letter?

Will a Review Results Letter be sent for an automated review?

What is the Review Results Letter process and what do I have to do?

I have more information to provide after reviewing my Review Results Letter.  How can I provide that information?

What justification will be included on the Review Results Letters?

Discussion Period

Do regulations govern the Discussion Period option?

If the hospital or provider wants to initiate a Discussion, what is the process to follow?

How does the Discussion procedure work?

How long will it take to receive the Discussion Results Letter?

How will I know if CGI Federal received and processed my Discussion request?

Should I wait for my Discussion Results or request a redetermination (Appeal) from the Medicare Claims Processor?

The Discussion Results Letter indicates that the initial findings were reversed.  Why did I still received a Demand Letter?

Overpayment Demand Letter

I received an Overpayment Demand Letter. What does it mean?

When is the Overpayment Demand Letter sent?

Why does it take so long after the Review Results Letter to receive my Demand Letter?

What is included in the content of the Overpayment Demand Letter?

What is the timeframe to pay the demand, from the Overpayment Demand Letter, to avoid interest accrual?

Recoupment

What is recoupment?

When does recoupment start?

When/how will I be notified when recoupment starts?

Will these recoupments appear on a separate Remittance Advice that clearly identifies they are the result of a RAC audit?

I have financial questions about the Remittance Advice; who is responsible to respond?

Can I make payment arrangements instead of auto recoupment?

Can I appeal?

Appeals

Do I have appeal rights?

What is the timeframe to appeal?

What are the levels of the appeal process?

DME

Who is the Durable Medical Equipment Medicare Administrative Contractor (DME Medicare Administrative Contractor) for Jurisdiction B (associated with RAC Region B)?

When does CGI Federal anticipate conducting recovery auditing functions for DME claims in Jurisdiction B?

What areas does CGI Federal intend to request CMS approval for DME audits?

 

 

 

 

 


Frequently Asked Questions

CGI Federal

What is the contact information for CGI Federal RAC Region B?

Phone number:  877-316-RACB (7222)

E-mail Address:  racb@cgi.com

CGI Medicare RAC Region B Website:  http://racb.cgi.com

 

What is the contract duration between CGI Federal and CMS?

The contract is a five year term.

 

Who are the Medicare Administrative Contractors (MACs), Fiscal Intermediaries (FIs) and Carriers for Region B?

The A/B Medicare Administrative Contractor, Durable Medicare Equipment Medicare Administrative Contractor and Home Health/Hospice Medicare Administrative Contractors, as well as the current FIs and Carriers are outlined below.  Please note that contractual protests may delay the implementation of a Medicare Administrative Contractor for a specific jurisdiction. 

 

Jurisdiction 6:

 

Jurisdiction 8:

 

 


Jurisdiction 15:

 

 

Durable Medical Equipment Medicare Administrative Contractor, Jurisdiction B: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin

JB-DME

 


Home Health/Hospice Medicare Administrative Contractor: Illinois, Indiana, Kentucky and Ohio

 


Home Health/Hospice Medicare Administrative Contractor: Michigan, Minnesota and Wisconsin

 

Provider Outreach

How often will CGI Federal provide onsite provider outreach?

CGI Federal will conduct outreach whenever feasible and practical.  Specific requests for Provider Outreach can be emailed to racb@cgi.com for consideration.

 

Will the outreach be done in person or via conferencing?

Outreach efforts will be done both in town hall meeting settings as well as web and audio conferences.

CGI Medicare RAC Region B Website

What is the website address for RAC Region B?

The CGI Medicare RAC Region B Website address is http://racb.cgi.com.

Provider Information, CGI Medicare RAC Region B Website

How do providers gain access to the Providers link on the CGI Medicare RAC Region B Website?

The CGI Medicare RAC Region B Website contains a Providers link on the main page.  Access to that portion of the Website is accomplished using Knowledge Based Authentication.  Providers must have either their Medicare ID or their NPI number.  In addition, providers must also have a unique piece of information from a letter the provider receives from CGI Federal (i.e. ADR Letter, Overpayment Demand Letter), or the “allowed amount” from a claim that was paid by Medicare within a specific date range.

 

How does the page functionality work?

The page will request an identification number that will serve as the username for the RAC Provider site (NPI or Medicare ID).  The page will request Knowledge Based information that will serve as the password for the RAC Provider Site (Letter ID or Allowed Amount). The page will look up the identification number for the provider and if it locates the information in the database, it will then display the inputs for the knowledge based password.

 

To request the username for the Provider, the page will request the provider type and an identification number entry field based on the provider type. 

 

·        The page will display a choice selection for “Part A” and “Part B” provider type. 

o   If the Provider selects “Part A” the page will display an input box for “Medicare ID”.

o    If the Provider selects “Part B”, the page will display an input box for “NPI”.

 

The “Medicare ID” or “NPI” will act as the username for the CGI Medicare RAC Region B Provider Website.

 

To request the password for the Provider, the page will display two different options for providing knowledge based information.  These prompts will be displayed only after the identification number for the provider has been located within the database.

 

The user will be given three (3) chances to enter the knowledge based information correctly.  If the user fails to enter the correct information within three tries, the page will stop the login process and display the RACB Call Center contact information.

 

·        If the provider has been sent a letter at least ten (10) days prior, the page will request the “Letter ID” from the most recent letter than was sent at least ten (10) days prior. 

o   The page will display the date of the letter.

o   The page will display an input box for the “Letter ID”.

 

·        If the provider has not been sent a letter at least ten (10) days prior, the page will display a request for information about Medicare claims the provider has filed.  Answering the question will be required and the information will be used to authenticate the user.

o   The page will display a prompt requesting the Medicare “Allowed Amount” for a recent claim.  A date range is displayed for the user.  The Medicare “Allowed Amount” must be from a claim within the displayed date range.  Any claim’s Medicare “Allowed Amount” within that date range can be entered.

 


The following options are displayed after a user is authenticated:

 

 

How does CGI Federal obtain RAC contact information for providers that is accessed on the CGI Medicare RAC Region B Website?

CGI Federal receives provider data from each Medicare Administrative Contractor/FI/Carrier.  This data was initially uploaded to our website.  In addition, CGI Federal receives periodic updated provider data and updates the provider database as appropriate.  Providers shall have one point of contact.  Providers are encouraged to log on to the Provider portion of the CGI Medicare RAC Region B Website to validate and update their contact information.  If no updates have been made to contact information by a provider, the initial Billing information supplied by the Medicare Administrative Contractor/FI/Carrier will be used to route all CGI Federal RAC correspondence.

 

How can providers update their contact information? 

1) Providers may contact the CGI RAC B Call Center to provide contact information updates.  The RACB Call Center staff will update the CGI Medicare RAC Region B Website directly with the information specified.  The RACB Call Center team will need the following information for each NPI for which updates are being provided:

 

Contact Name:

Contact Address: (Including City, State, and Zip Code)

Contact Phone Number:

Contact E-mail Address:

Name of Facility/s:

Facility NPI Numbers:

(ALL Facilities and Group NPI numbers listing departments that you will be representing.  If you have multiple physician NPI's and they are all billed under the same GROUP NPI we would need only the group NPI.)

Facility TIN Numbers:

Facility Medicare IDs:

 

info_blue

If updating a large number of contacts, please contact the CGI RAC B Call Center. The Call Center will provide you with an Excel Template to use for this purpose.  We prefer to receive Excel documents in our format so we can expedite the processing of the updates to our system.

 

2) By using the Providers link on the CGI Medicare RAC Region B Website.  Providers can view and modify their own contact information with the available functionality.

 

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If you are updating your contact information and wish all RAC correspondence to be sent to the updated contact, please update BOTH the Mailing Address and the Billing Address.

 

Please note that we have added additional functionality to ensure that contact information is accurately applied.  When logging in with either the Medicare ID or an NPI, providers will only be able to update contact information for addresses that share the Tax ID of the information entered for the logon identity.  The new functionality will work as outlined below:

 

Scenario 1

If the provider has only one address associated with their login identity, the page will provide two basic functions.  It will give the user with the ability to verify their address information and provide the ability to modify the address information if it is incorrect.  The user will be able to modify addresses that have an associated Tax ID.  If no Tax ID is available for the provider, the address information will be read-only.

 

Scenario 2

The page will provide the ability to modify the provider’s address information if it is associated with a Tax ID, and it will also allow the provider to apply or copy that address information to one or more of the addresses that are associated with their login identity, provided those additional addresses have a matching Tax ID.

 

Address Verification

Users will be able view the current address information and click the “Verify Address Information” button to verify that all address information is correct.

 

Address Modification

Users will be able click the “Modify Address Information” button to navigate to the address modification screen.

 

How do I use the claim status function on the Providers link?

After properly authenticating to the site, the user will select the Claim Audit Status link.  This page will display all claims where an Additional Documentation Request was made to the provider.  The provider will be able to sort columns by all fields listed.  The screen will provide paging for large lists of claims.  The screen will provide the allowed number of medical records requests.  The provider will also be able to filter or search claims based on Status, Letter Number, Status Date or Due Date. 

 

The display will change depending on the search criteria selected as follows:

 

An additional function is the Claim Audit Details link. 

 

This link will display information regarding a specific RAC Case. 

 

 

In addition to those displayed in the picture above, the following changes are also available.

 

Appeal In Process:  An appeal has been received by CGI Federal from the claims processor.
Appeal Completed:   An appeal has been finalized by the claims processor.

 

How will CGI Federal communicate important information to the provider community?

CGI Federal has initiated a Bulletin Board function for communicating important information to the provider community.  The Bulletin Board is available, once a provider is authenticated to the provider portion of the CGI Medicare RAC Region B Website, by selecting the Home link.   

New Issues, Areas for Review

What areas does CGI Federal intend to request CMS approval for audit?

CGI Federal is required to obtain CMS approval for all areas of review that we have identified.  Any potential new issue must be reviewed and approved by CMS and then posted to the CGI Medicare RAC Region B Website before we can perform a review.  CMS approved areas of review will be posted on the CGI Medicare RAC Region B Website. 

 

How will CGI Federal communicate new issues for review to state hospital associations?

CGI Federal encourages state hospital associations to view all CMS approved new issues on the CGI Medicare RAC Region B Website, http://racb.cgi.com.  Additionally, the provider outreach team works with state associations and other identified parties to share RAC information.

 

Sample from the Issues link on the CGI Medicare RAC Region B Website:

tip.jpg  The information can be sorted by any of the fields that are underlined.

 

 

Sample of Issue Details:

 

On the CGI Medicare RAC Region B Website, under Issues and then under Claims Types, when you include the word “Physician”, are you referring to private practices as well as Hospital Physicians?

Yes, the reference is to private practice physicians as well as hospitals.

Auditing

How are claims selected for audit?

CGI Federal will use proprietary software and systems as well as our knowledge of Medicare rules and regulations to determine what areas to review.

 

Who will be auditing my claim?

Physicians, registered nurses, therapists and certified coders will be utilized to perform complex medical reviews.

 

Will all audits be conducted at the facility or provider location?

No, all audits will not be conducted onsite at a facility or provider location.  A determination of whether to conduct an onsite audit will be made based on the scope as well as the volume of medical records to be reviewed.

 

If an onsite audit is scheduled, how many CGI Federal staff will be assigned to review at the provider site?

Assignment will depend on the scope of the audit as well as the volume of medical records to be reviewed.

 

Where are CGI Federal auditors located?

CGI Federal has a staff of excellent, experienced medical auditors located in many states across the country. 

 

What is done to protect confidential data during an audit?

All provider data is managed according to HIPPA guidelines.

 

What is the maximum number of CGI Federal staff that could be physically present at the provider site?

CMS has indicated that no more than two auditors will be part of an onsite audit team, provided an onsite review is scheduled. 

 

How often will CGI Federal conduct onsite provider reviews?

CGI Federal will make those decisions on a case-by-case basis.

 

If CGI Federal denies a hospital claim for services, will they also deny the physician claim for services?

No, Part A and Part B claims will be reviewed independently according to CMS guidelines.

 

What utilization criteria will CGI Federal be using to review for medical necessity?

CGI Federal will utilize the rules for National Coverage Determinations (NCD), Local Coverage Determinations (LCD), HCPCS, ICD-9 (ICD-10 when implemented and appropriate) and CCI that were in effect on the date of service.

 

Will the RAC review any other Medicare plans, such as Medicare Advantage?

The RAC will review Non-MSP Medicare Fee-for-Service claims only.  Medicare Advantage claims are not in scope for the RAC project.

 

Will CGI Federal accept physicians’ notes from their offices to support the request for services?

Yes.  Providers are encouraged to submit all supporting documentation with the initial medical record request.  During the Discussion Period, supporting evidence for a request for services will be accepted.

Underpayments

What is an underpayment?

A Medicare underpayment is defined as those lines or payment group (e.g., APC, RUG) on a claim that was billed at a low level of payment.  The services should actually have been billed at a higher rate; thus, resulting in a refund to the provider.

 

How is it determined that an underpayment was identified?

CGI Federal will use proprietary algorithms to determine underpayments as well as overpayments.  CGI Federal reviews each claim line or payment group and considers all possible occurrences of an underpayment that are in that one line or payment group.

 

What is the process when CGI Federal identifies an underpayment?

CGI Federal reviews claims using automated or complex reviews, to identify potential Medicare underpayments.  Upon identification, CGI Federal communicates the underpayment finding to the appropriate Medicare Administrative Contractor/FI/Carrier.  Once the appropriate Medicare Administrative Contractor/FI/Carrier has validated the Medicare underpayment, CGI Federal issues a written notice to the provider.  The Underpayment Notification Letter includes the claim(s) and beneficiary detail. 

 

Why are medical records being requested for an underpayment?

CGI Federal will request the medical record, if necessary, to substantiate the validity of the underpayment.

 

When will CGI Federal reimburse providers for the payment of requested medical records sent for an underpayment?

CGI Federal will pay for copies of medical records associated with review of acute care inpatient prospective payment system (PPS) hospital (DRG) claims and long-term care hospital claims.  CGI Federal is required to pay for medical records within 45 days of receiving the medical record. 

 

When will I get my underpayment money returned from the Medicare Administrative Contractor/FI/Carrier?

Once the Medicare Administrative Contractor/FI/Carrier adjusts the underpayment and the underpayment processes through the system, the adjustment will be included on the provider’s next available remittance advice.

 

Can I appeal an underpayment?

Yes.  Underpayments are initial determinations, subject to appeal rights.  Please note however, that the provider may utilize an initial discussion period to present any concerns to the RAC prior to initiating an appeal.

 

Can CGI Federal provide a draft timeline for underpayments so the providers can better understand the framework that CGI is utilizing?

 

Overpayments

What is an Overpayment?

A Medicare overpayment is defined as those claim lines or payment groups (e.g., units, APCs, RUGs, etc.) on a claim that were billed incorrectly.  The documentation does not support services billed, the payment exceeds the Medicare allowed amount or Medicare made a payment for non-covered services or items.

 

I received notice of an identified overpayment.  What does it mean?

The notice of an identified overpayment indicates that CGI Federal will pursue the recoupment of Medicare overpayments in accordance to the guidelines set by CMS.

 

How is it determined that an overpayment was identified?

CGI Federal will identify a claims overpayment where there is supportable evidence of the overpayment.  There are two primary ways of identification:

1.      Through “automated review” of claims data without human review of medical or other records

2.      Through “complex review” which entails human review of a medical record or other documentation 

 

The determination process for identifying overpayments is summarized in four steps:

 

  1. CGI Federal documents the rationale for the determination listing the review findings with a detailed description of the Medicare policy that was violated.
  2. The review goes through the validation process which may require further review from the Medicare Administrative Contractor/FI/Carrier but essentially routes to CMS for final validation.
  3. CGI Federal communicates with the provider about improper payment (Review Results Letter).
  4. Depending on whether the determination is either a full or partial denial, the overpayment amount is determined.

 

What is the dollar limit for a denial determination on an overpayment?

CGI Federal does not recoup or forward any claim to the Medicare Administrative Contractor/FI/Carrier for adjustment if the amount of the overpayment is less than $10.  Claims less than $10.00 cannot be aggregated and recouped. 

 

What if I do not agree with the Review Results Letter?

A provider has an initial Discussion Period to present additional information to support the services billed.  If the provider does not agree with the decision, then the provider has 120 days from date of the Overpayment Demand Letter to file an appeal of the determination; see Discussion Period.

 

Automated Review

What is an automated review?

An automated review is a review that occurs when CGI Federal makes a claim determination at the system level without a human review of the medical record. 

 

Can I appeal on an automated review?

Yes.  The first level of an appeal is called a redetermination and is handled through the provider’s Medicare Administrative Contractor/FI/Carrier. A provider will have 120 days from the date of the Overpayment Demand Letter to file an appeal. The provider may forward their appeal request and all supporting documentation to the provider’s Medicare Administrative Contractor/FI/Carrier.

 

What procedure does CGI Federal plan to utilize to coordinate recoupments with the Medicare Administrative Contractor/FI/Carriers?

CGI Federal forwards all identified improper payments to the Medicare Administrative Contractor/FI/Carriers.  The recovery techniques shall follow the recovery guidelines of all applicable CMS regulations and manuals, as well as all federal debt collection standards.

 

Semi-Automated Review

What is an semi-automated review?

A semi-automated review is a two-part review that is now being used in the Recovery Audit Program.  The first part is the identification of a billing aberrancy through an automated review using claims data.  This aberrancy has a high index of suspicion to be an improper payment.  The second part includes a Notification Letter that is sent to the provider explaining the potential billing error that was identified.  The letter also indicates that the provider has 45 days to submit documentation to support the original billing.  If the provider decides not to submit documentation, or if the documentation provided does not support the way the claim was billed, the claim will be sent to the Medicare claims processing contractor for adjustment and a demand letter will be issued.  However, if the submitted documentation does support the billing of the claim, the claim will not be sent for adjustment and the provider will be notified that the review has been closed. 

 

Does the RAC still have 60 days to complete the review upon receipt of a medical record?

Yes.

 

Will providers receive a letter with the results of the review?

If the provider submitted supporting documentation, they will receive a Review Results letter.

 

Will providers still have the Discussion Period option for a semi-annual review?

Yes.

 

Can I appeal on a semi-automated review?

Yes.  The first level of an appeal is called a redetermination and is handled through the provider’s Medicare Administrative Contractor/FI/Carrier. A provider will have 120 days from the date of the Overpayment Demand Letter to file an appeal. The provider may forward their appeal request and all supporting documentation to the provider’s Medicare Administrative Contractor/FI/Carrier.

Complex Review

What is a complex review?

Complex medical review involves the application of clinical judgment by a licensed medical professional or certified coding specialist in order to evaluate medical records.  Medical records include any medical documentation, other than what is included on the face of the claim that supports the services that are billed. CGI Federal will use complex medical review in situations where there is a high probability (but not certainty) that the service is not covered or where no Medicare policy, Medicare article or Medicare sanctioned coding guideline exists.  During a complex review, CGI Federal will request medical records to substantiate services billed.

 

Can I appeal a complex review?

Yes, a provider has 120 days from the date of the Overpayment Demand Letter to file an appeal of the determination to the Medicare Administrative Contractor/FI/Carrier.

Additional Documentation Limits

What are Additional Documentation Limits?

Additional Documentation Limits are the number of medical records that can be requested by a RAC for review during a 45 day period.  Limits have been instated by CMS to ensure the number of medical records in the request do not negatively impact the provider’s ability to provide care.

 

Additional Documentation Limits for Medicare providers (except suppliers and physicians)

 

Beginning April 15, 2013, the additional documentation requests limits will follow the guidelines below:

 

A. The maximum request amount is per campus. The definition of campus is one or more facilities under the same Tax Identification Number (TIN) located in the same area (using the first three positions of the ZIP code). This is different than the definition used for provider-based status.

 

For example:

      Provider A has TIN 123456789 and two physical locations in ZIP codes 12345 and 12356; the two locations would count as one campus unit.

      Provider B has TIN 123456780 and is physically located in 12345 and 21345. Each location is counted separately. Each location has its own limit.

 

B. Each limit is based on the Medicare claims volume from the previous calendar year.

 

C. In addition to a limit based on the Medicare claims volume, claim type will also factor into the limit. Recovery Auditors may select up to 75% of any claim type for review. For example, if a provider has submitted both Part A and Part B claims, the Recovery Auditor may select only 75% of the calculated ADR from Part A claims. The balance of the calculated ADR may be selected from Part B claims.

 

D. The maximum number of requests per 45 days is 400.

   Providers with over $100,000,000 in MS-DRG payments who were notified by CMS of an increased cap of 500 requests will now have a cap of 600.

 

E. Recovery Auditors may request up to 20 records per 45 days from providers whose calculated limit is 19 additional documentation requests or less.

 

F. The limit is equal to 2% of all claims submitted for the previous calendar year divided by 8. The Recovery Auditors may go more than 45 days between record requests but may not make requests more frequently than every 45 days. A provider’s limit will be applied across all claim types, including professional services.

 


Note:    Fiscal Year limits are based on all submitted claims (paid or denied). Interim/final bills and RAPs/final claims are considered one unit.  For example:

•       Provider C billed 156,253 claims last year, consisting of Part A and Part B claims. Two percent of the claims volume is 3,125. The limit is calculated by dividing 3,125 by 8. The provider’s ADR is no more than 391 requests every 45 days. Because there is also a 75% limit on any particular claim type, only 294 Part A claims may be selected for review. The difference of 97 requests may be selected from Part B claims.

 

•       Provider D billed 426,000 claims last year, consisting of Part A and Part B claims. Two percent of the claims volume is 8,520. The limit is calculated by dividing 8,520 by 8. This is equal to 1,065 requests per 45 days.  Since their previous year MS-DRG payments exceed $100,000,000, the provider’s ADR is limited to the maximum cap of 600 requests. Because there is also a 75% limit on any particular claim type, only 450 Part A claims may be selected for review. The difference of 150 requests may be selected from Part B claims.

 

G. For Skilled Nursing Facility (SNF) claims, one additional documentation request represents a beneficiary’s entire episode of care. This includes medical records for all services rendered from the date of admission to the final date of discharge.

H. CMS may give the Recovery Auditors permission to exceed the limit. Permission to exceed the limit may occur by CMS’s own initiative or from the Recovery Auditor requesting permission. CMS or the Recovery Auditor will notify affected providers in writing.

The table below summarizes changes to the additional documentation request limits; specific changes are noted in bold font:

 

Old

New

Campus Concept

Campus Concept

100% of any claim type

75% Limit on any particular claim type

400 ADR cap /maximum every 45 days

400 ADR cap /maximum every 45 days

         If >$100M annual revenue, then 600

         If >$100M annual revenue, then 600

35 minimum record request

20 minimum record request

2% of Medicare claims volume

2% of Medicare claims volume

Exceptions allowed

Exceptions allowed

 

Questions concerning this update can be directed to RAC@cms.hhs.gov.

 

More information on limits can be found on the CMS website, including Physician and Supplier limits; under the Program Providers Resources link.

 

How can I view our Additional Documentation Limits?

Provider Medical Record Limits can be viewed from the Additional Documentation Request Limits link on the provider portion of the CGI Medicare RAC Region B Website.

 

What if I disagree with the Additional Documentation Limits calculations?

Providers can contact the CGI Medicare RAC B Call Center.  CGI Federal will work with the providers to help to explain what constitutes the limits that were calculated.

 

Medical Records Request (ADR Requests)

How can a provider send requested medical records to CGI Federal?

See also Medical Record Submission Instructions from the link on the left side of the Home Page of the CGI Medicare RAC Region B Website.

 

Medical Record Request Guidelines

 

Medical Record Submission Instructions

Medicare’s CGI RAC Region B

 

Records are accepted electronically in ESMD (Electronic Submission of Medical Documents), paper, Fax or CD/DVD format.


Due Date: 45 days
from the date on the Additional Documentation Request Letter (Medical Record Request Letter).

 

ESMD:

·        CGI encourages providers to submit medical records via ESMD (Electronic Submission of Medical Data).

·        When sending records via ESMD, please include a CASE ID number in your file transmission.  Refer to the “ESMD Information Link” on the RACB Website for detailed information and instructions.

 

Paper Records:

·        Paper medical records must meet the following requirements:

 

Faxed Records:

·        Faxed medical records must meet the following requirements:

·        Medical records can be faxed to the following numbers. This Fax line is for incoming medical records only.

o   For Illinois, Indiana, Kentucky, Michigan, Ohio, DME and Home Health 1-216-902-3860

o   For Minnesota and Wisconsin 1-866-340-0626

·        Medical records submitted via Fax, must be transmitted as individual files (one medical record per transmission) in order for the records to process.

·        Multiple medical records in a single file transmission cannot be processed.

 

CD/DVD:

·        Medical records submitted via CD/DVD must meet the following requirements:

·        Scanned image resolution must be 200 dpi and in black and white.

·        Image must be in the TIFF, with Group 4 compression, or in PDF format.  CGI would prefer the TIFF format.  For the use of any other formats, please contact the CGI RAC Region B Call Center at 1-877-316-RACB (7222) prior to sending the files.

·        Multipage documents must be saved in one image.  For example, a 50 page medical record will be one image file.

·        Scanned image must be legible.

·        The image file naming convention must be as follows; <Patient Name>_<Admit Date/Date of Service>.  For example, if the Patient Name is John Smith and the date of service is October 1, 2008, then the file will be named JohnSmith_10012008.tif.

·        Include a copy of the CGI RACB Additional Documentation Request Letter (Medical Record Request Letter). You can include the ADR letter on the CD/DVD, but please do not encrypt it. However; all Medical Records must be encrypted.

 

Medical Record Submission:

·        All medical records requested on the ADR should be submitted on a single CD/DVD.

·        Individual medical records should not be submitted on individual CD/DVDs.

·        Label the CD or DVD according to the following naming convention; <Provider Facility Name>_<medical record request letter date in YYYYMMDD format>.  Example:  MercyHospital_20091212.

·        Please send all medical records, both paper and CD or DVD, in tamper proof packaging, such as security mailers, tamper evident mailers, or security labels.

 

Encryption:

·        For security purposes, all images sent via CD/DVD should be encrypted either in a WinZip file that is password protected, or by using PGP encryption.

·        Encrypt the CD/DVD only; not the individual medical record files on the ADR Letter.

·        Encrypted medical record files cannot be processed.

·        For encrypted WinZip files:  Use your Additional Documentation Request Letter ID (medical record request letter) as the password.   For Providers that use a version of WinZip that requires 8 characters to encrypt, please place zeros BEFORE the Letter ID; i.e. 00075231.

·        For encrypted PGP files:  Contact CGI RAC Region B prior to shipment to obtain the Public Encryption key.  This can be accomplished by calling our CGI RAC Region B Call Center at 1-877-316-RACB (7222).

 

 

Send medical records as follows:

 

Medical records for Indiana, Illinois, Kentucky, Michigan, Ohio, DME and Home Health:

 

CGI Federal Inc.

Attn: RACB Imaging Dept

1001 Lakeside Ave., Suite 800

Cleveland, OH 44114

 

Medical records for Minnesota and Wisconsin:

 

Attn: Medicare Recovery Audit Subcontractor - Region B

PO BOX 72488

Atlanta, GA 31139

 

Pre-payment Therapy Reviews

Where do I mail medical records for pre-pay therapy reviews?

 

 

 

Pre-Payment Review Medical Record Submission Instructions

Medicare’s CGI RAC Region B

 

Records are accepted electronically in ESMD (Electronic Submission of Medical Documents), paper, Fax or CD/DVD format.


Due Date:  30 days
from the date on the medical record request letter.

 

ESMD:  CGI encourages providers to submit medical records via ESMD (Electronic Submission of Medical Data).

 

Faxed Records:  Faxed medical records must meet the following requirements:

 

CD/DVD:

·        Medical records submitted via CD/DVD must meet the following requirements:

·        Scanned image resolution must be 200 dpi and in black and white.

·        Image must be in the TIFF, with Group 4 compression, or in PDF format.  CGI would prefer the TIFF format.  For the use of any other formats, please contact the CGI RAC Region B Call Center at 1-877-316-RACB (7222) prior to sending the files.

·        Multipage documents must be saved in one image.  For example, a 50 page medical record will be one image file.

·        Scanned image must be legible.

·        The image file naming convention must be as follows; <Patient Name>_<Admit Date/Date of Service>.  For example, if the Patient Name is John Smith and the date of service is October 1, 2008, then the file will be named JohnSmith_10012008.tif.

·        Include a copy of the Additional Documentation Request Letter (medical record request letter) from the Medicare Administrative Contractor.  You can include the ADR letter on the CD/DVD, but please do not encrypt it. However; all Medical Records must be encrypted.

 

Medical Record Submission:

·        Label the CD or DVD according to the following naming convention; <Provider Facility Name>_<medical record request letter date in YYYYMMDD format>.  Example:  MercyHospital_20091212.

·        Please send all medical records, both paper and CD or DVD, in tamper proof packaging, such as security mailers, tamper evident mailers, or security labels.

 

Encryption:

·        For security purposes, all images sent via CD/DVD should be encrypted either in a WinZip file that is password protected, or by using PGP encryption.

·        For encrypted WinZip files:  Please contact the CGI RAC Region B Call Center prior to shipment to obtain the password. This can be accomplished by calling 1-877-316-RACB (7222).

·        For encrypted PGP files:  Contact CGI RAC Region B prior to shipment to obtain the Public Encryption key.

 

Paper Records:  Paper medical records must meet the following requirements:

 

If submitting paper records, CDs or DVDs, please send medical records as follows:

 

For Therapy Reviews in the states of Illinois, Michigan and Ohio only:

 

CGI Federal Inc.

Attn:  RACB Imaging PREPAY OT

1001 Lakeside Avenue, Suite 800

Cleveland, OH 44114

 

For Therapy Reviews in the states of Minnesota and Wisconsin only:

           

                        RAC Subcontractor – Region B

                        PO Box 723027

                        Atlanta, GA 31139

 

For all other reviews - Medical records for Illinois, Michigan and Ohio:

 

CGI Federal Inc.

Attn:  RACB Imaging PREPAY

1001 Lakeside Avenue, Suite 800

Cleveland, OH 44114

 

 

 

 

If we submit more than one DVD, do the DVDs need to be labeled 1 of 3, 2 of 3, 3 of 3?

Yes, we recommend the following as shown in the example:  MercyHospital_20091212_1, MercyHospital_20091212_2, MercyHospital_20091212_3.

 

May we place all DVDs in one package and provide one copy of the CGI RAC B Additional Documentation Request Letter?

Yes.  Please note if there is more than one ADR Letter, all copies should be included in the package.

 

If I send records on a CD or DVD, do they need to be encrypted?

For security purposes, all images sent should be encrypted either in a WinZip file that is password protected, or by using PGP encryption.

 

When CGI Federal requests the entire Medical Record, do we need to send the UB04?

Yes.  Please include this with the Medical Records that are submitted.

 

How long does the provider have to send in the medical records?

CGI Federal must receive the medical record within 45 days of the date of the Additional Documentation Request Letter (CGI’s request for Medical Records letter).

 

What happens if the provider misses the deadline?

Providers will receive a reminder notice from CGI Federal prior to the deadline.  If the medical record is not received within 45 days, the claim may be denied.  However, CGI Federal will work with providers who may be concerned about meeting the deadline.

 

Will CGI Federal pay for all requested medical records or just certain types?

CGI Federal will pay for copies of medical records associated with review of acute care inpatient prospective payment system (PPS) hospital (DRG) claims and long-term care hospital claims.

 

What is the amount that CGI Federal will pay for medical records?

RACs, including CGI RAC B, shall comply with the formula calculation found at 42 CFR §476.78(c) of the Code of Federal Regulations, Title 42 – Public Health.

 

Will CGI Federal pay for postage?

Yes, CGI Federal will reimburse providers for First Class postage for medical records sent to us that are associated with review of acute care inpatient prospective payment system (PPS) hospital (DRG) claims and long-term care hospital claims.  If a package is sent to us via an overnight carrier, or some other method other than First Class postage, CGI Federal will reimburse for the equivalent of First Class postage.

 

Do I need to send CGI Federal an invoice for postage?

No, CGI Federal will calculate the amount of postage and send a check, at least every 45 days, to providers.

 

If a hospital or provider utilizes an electronic medical record system, what documentation will they be required to provide to CGI Federal?

The provider must submit all documentation that support the services rendered.  The Additional Documentation Request Letter will contain a detail listing of all documentation being requested.

 

I never received an Additional Documentation Request Letter and now I have an Overpayment Demand Letter.  What do I do?

Contact CGI Federal immediately to ensure that CGI has the correct provider contact information.  Note that Additional Documentation Request Letters are only sent for Complex Reviews.  You will not receive one for an Automated Review.  Note that a determination may be appealed up to 120 days from the date of the Overpayment Demand Letter.

Review Results Letter

How will CGI Federal send the Review Results Letter?

Review Results Letters will be sent via US Postal Service Regular First Class mail.

 

Will a Review Results Letter be sent for an automated review?

No.  The provider will receive only the Overpayment Demand Letter for an automated review.  This letter will contain the rationale for denial and regulation that was violated, in addition to, appeal rights information.

 

What is the Review Results Letter process and what do I have to do?

Once CGI Federal has received the requested medical records from a provider, the audit team has 60 calendar days from receipt of medical records to review all supporting documents in the record, make a claim determination and send the Review Results Letter to the provider.  Providers are afforded the Discussion option to provide additional documentation or discuss the results.    

 

I have more information to provide after reviewing my Review Results Letter.  How can I provide that information?

Providers have an initial discussion period to provide supporting documentation.  Every effort should be made to send all requested information in response to the Additional Documentation Request Letter.  Instructions for providing further evidence or information are included in the Review Results Letter.  In addition, providers can contact the CGI Medicare RAC B Call Center at 1-877-316-RACB (7222) or via e-mail at racb@cgi.com.

 

What justification will be included on the Review Results Letters?

The Review Results Letter will document all rationale for the claim determination.  These rationales will include a detailed description of the Medicare policy or rule that was violated and a statement as to whether the violation resulted in an improper payment.

Discussion Period

Do regulations govern the Discussion Period option?

The discussion period is a contractual requirement developed as a courtesy to the Provider community for the RAC program and it does not supersede or replace the statutory appeals and/or recoupment timeframes.

 

If the hospital or provider wants to initiate a Discussion, what is the process to follow?

Prior to any recoupment taking place for identified overpayments, CGI Federal, in accordance with CMS guidelines, provides a Discussion Period, to allow the provider to discuss medical/clinical results with appropriate CGI Federal personnel.  The Discussion may be conducted in writing or via teleconference.

 

It is highly recommended that you contact CGI Federal as soon as possible to initiate any discussions well in advance of recoupment.  Keep in mind that the Discussion does not stop the Recoupment timeframe or process.

 

Outlined below are guidelines for using this Discussion Period:

 

To initiate a discussion, download the Discussion Period Request form from the FAQ area of the Medicare RAC Region B Website, complete the information requested, and fax or mail to CGI Federal as shown in the instructions attached to the form.  

 

Please note that CGI Federal has implemented a fax number for use in specifically faxing Discussion Requests for Illinois, Indiana, Kentucky, Michigan, and Ohio. 

 Please note that only Discussion Requests will be accepted to this dedicated Discussion fax line.   

For the listed states, Medical Records should continue to be faxed as outlined below.

 

DISCUSSION REQUEST FAX NUMBER For Illinois, Indiana, Kentucky, Michigan and Ohio and for DME and Home Health
216-687-4278

 

DISCUSSION REQUEST FAX NUMBER For Minnesota and Wisconsin:
866-340-0626

 

MEDICAL RECORD FAX NUMBER For Illinois, Indiana, Kentucky, Michigan and Ohio and for DME and Home Health
216-902-3860

 

MEDICAL RECORD FAX NUMBER For Minnesota and Wisconsin:

866-340-0626

 

If you have any questions regarding this process, you may contact CGI RAC B Call Center at 1-877-316-RACB (7222) or email to racb@cgi.com.

 

How does the Discussion procedure work?

Providers can initiate a Discussion as soon as they receive the Review Results Letter and up to DAY 40 from the date of the Demand Letter.

 

Our experience indicates that the Discussion process can be handled more quickly and effectively if a written request and additional documentation are faxed to CGI Federal for review rather than receiving the request by phone.   We have also found that many of the requests, particularly when additional documentation is submitted to support the claim, can be resolved without the need for a teleconference.

 

Once CGI Federal is in receipt of a written Discussion request, the auditor and, if needed, the Medical Director will determine if a telephone discussion is necessary, or if a complete and appropriate response can be provided in writing based on the submitted documentation only. If a teleconference is necessary, CGI Federal will contact the provider to arrange a time.  Upon completion of a Discussion, a Discussion Results Letter will be sent that details the outcome of the written or oral discussion.

 

How long will it take to receive the Discussion Results Letter?

Discussions are managed on a schedule and Discussion Results Letters are generated and mailed once per week.  Most providers receive the Discussion Results Letter within two weeks from the closure of the Discussion.

 

How will I know if CGI Federal received and processed my Discussion request?

Once authenticated from the Providers link on the CGI Medicare RAC Region B Website, current case status can be viewed from the Claim Audit Details link.  Once in receipt of the Discussion request, the case status will be set at Discussion Open.  When a Discussion is finalized, whether written or via teleconference, the case status will be set at Discussion Letter Sent. 

 

Should I wait for my Discussion Results or request a redetermination (Appeal) from the Medicare Claims Processor?

This is a decision that the provider must make.  Note that if an appeal is initiated prior to the finalization of the Discussion process, the RAC decision could be jeopardized.

 

The Discussion Results Letter indicates that the initial findings were reversed.  Why did I still received a Demand Letter?

In some cases, due to timing, an AR will be established with the Claims Processor prior to the processing of a reversal based on a discussion.  In these cases, providers will see the overpayment on a remit and receive a Demand, however, the reversal will be processed.

 

Overpayment Demand Letter

I received an Overpayment Demand Letter.  What does it mean?

Once an overpayment is discovered and a final determination is made, an Overpayment Demand Letter is sent.  The RAC is required to follow the same practices for sending an Overpayment Demand Letter as those applicable to Medicare Administrative Contractors. Overpayment Demand Letters instruct providers to send payment to the Medicare Administrative Contractor. Payments received by the Medicare Administrative Contractor are deposited and the Medicare Administrative Contractor is required to update the RAC within seven calendar days of applying the payment.

 

When is the Overpayment Demand Letter sent?

During either an automated or complex review, the Overpayment Demand Letter is sent in conjunction with the issuance of the Remittance Advice from the Medicare Administrative Contractor/FI/Carrier.  Providers may receive their Remittance Advice first, before the Overpayment Demand Letter from CGI Federal. 

 

Why does it take so long after the Review Results Letter to receive my Demand Letter?

When an improper payment determination is made during a complex review of a medical record, the RAC issues a Review Results Letter to the provider and forwards the claim adjustment to the claims processing contractor.  The adjustment is validated for data elements.  Once validated, the data files are returned with the AR dates for the claims. 

 

There are no statutory or contractual timeframes associated with the processing of a RAC adjustment by a claims processor.  Once a RAC adjustment is forwarded to a claims processor by a RAC, the RAC must wait until the adjustment is processed and the Remittance Advice Notice (RA) is generated before the RAC is able to send out an Overpayment Demand Letter.  The Demand Letter initiates all Statutory time frames (e.g., Provider appeal timeframe, overpayment recoupment timeframes in the case of an overpayment).

 

Several factors may contribute to the delay in processing, some of the most common causes for delay are errors in claim data validation, and the fluidity of a claim.

 

i_blue.jpg Each error has to be individually researched and resolved between the RAC and the claims processor.  We continue to work with the claims processors, as well as continuing evaluation of our own processes, to help expedite this process. 

 

What is included in the content of the Overpayment Demand Letter?

A sample of the RAC B Overpayment Demand Letter (Automated) is posted on the CGI Medicare RAC Region B Website for providers’ convenience.

 

What is the timeframe to pay the demand, from the Overpayment Demand Letter, to avoid interest accrual?

If an overpayment is not paid in full or a valid appeal is not filed within 30 days of the date of the Overpayment Demand Letter, interest will start accruing on day 31.

Recoupment

What is recoupment?

Recoupment is defined as the recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare provider payments and applying the amount withheld to reduce the debt.  The claims processing contractor (Medicare Administrative Contractor/FI/Carrier) handles recoupment of payments.

 

When does recoupment start?

If a full payment is not received 40 days after the date of the Overpayment Demand Letter and the provider does not file an appeal in the first 40 days of receipt of the Overpayment Demand Letter, the claims processing contractor (Medicare Administrative Contractor/FI/Carrier) will begin the recoupment process on day 41.

 

When/how will I be notified when recoupment starts?

The provider will be notified of the date in the Overpayment Demand Letter.

 

Will these recoupments appear on a separate Remittance Advice that clearly identifies they are the result of a RAC audit?

The provider will receive an Overpayment Demand Letter from the RAC, in addition to a Remittance Advice notice from the claims processing contractor (Medicare Administrative Contractor/FI/Carrier), containing details of the automated findings.  Once fully implemented by the CMS, Standard System Maintainers, reason code N432 will be used on the Remittance Advice to identify adjustments based on a RAC review.

 

I have financial questions about the Remittance Advice; who is responsible to respond?

Education on the Remittance Advice Notice and Medicare recoupment process is the responsibility of the claims processing contractors (Medicare Administrative Contractor/FI/Carrier). A Remittance Advice Notice is generated by the claims processing contractor to indicate an adjustment to a claim.  The Medicare recoupment process and its associated timeframes as cited in the Medicare Financial Management Manual (Chapter 4 – Debt Collection) are not altered based on a RAC audit, and are available to Providers both in hardcopy and on the Medicare Online Manual.

 

Can I make payment arrangements instead of auto recoupment?

Yes, a provider can repay the Medicare Administrative Contractor/FI/Carrier within 30 days, interest free; interest accrual begins on day 31from the date of the Overpayment Demand Letter.  Providers can request an extended repayment plan by contacting the CGI Medicare RAC B Call Center. 

 

Can I appeal?

Yes, providers can appeal up to 120 days after the date of the Overpayment Demand Letter.

Appeals

Do I have appeal rights?

Yes.  The first level of an appeal is called a redetermination and is handled through the Medicare Administrative Contractor/FI/Carrier.  Providers will forward appeal requests and all supporting documentation to the Medicare Administrative Contractor/FI/Carrier.  More information on appeals can be found at the CMS RAC Website, http://www.cms.hhs.gov/RAC/, under Related Links Inside CMS.

 

RACs are required to provide support to appeal entities, including providing all case documentation to the appeal entities, however, appeal determinations at any level of appeal are made independent of the initial RAC determination. 

 

What is the timeframe to appeal?

The timeframes to appeal are outlined in the diagram below. 

 

What are the levels of the appeal process?

The levels of appeal are outlined in the diagram below. 

 

DME

Who is the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction B (associated with RAC Region B)?

National Government Services, Inc. was awarded the Jurisdiction B DME Medicare Administrative Contractor for the RAC Region B states of Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin.

 

When does CGI Federal anticipate conducting recovery auditing functions for DME claims in Jurisdiction B?

In accordance with the RAC expansion schedule, CGI Federal must perform all initial RAC outreach activities, submit and gain CMS approval for new issues for review and post approved new issues to the CGI Medicare RAC Region B Website before implementing DME auditing functions.

 

What areas does CGI Federal intend to request CMS approval for DME audits?

Through data analysis, providers are identified for targeted review.  Claims are selected as those claims that are most likely to contain an improper payment (coding error, coverage issue or medical necessity).