Exhibit-Sample Letter--Request For Medical Records - (Rev. )

7.2 - Exhibit-Sample Letter--Request For Medical Records - (Rev. ) The intermediary uses the following letter to request necessary medical records from the provider. DATE: PROVIDER NAME: INTERMEDIARY NAME: PROVIDER ADDRESS: INTERMEDIARY ADDRESS: PROVIDER NUMBER: OPENING: Dear XXXXX: You have been selected for a comprehensive medical review (CMR) of your billing for Medicare services pursuant to CMS’s statutory and regulatory authority. You were selected for this review because our analysis of your billing data indicates that you may be billing inappropriately for services. We have selected a random sample of ___ claims for services provided during the period _____ through _____. (See attached listing.) For each of these claims, we are requesting the following information: [The following list is for illustrative purposes. MR should request any documentation that will permit them to conduct a thorough review of the claims submitted with regard to coverage, eligibility, medical reasonableness and necessity, limitation on liability determinations (§1879), without fault determinations (§1870), etc.] • Form HCFA-485; • Form HCFA-486, or equivalent information, if applicable; • Form HCFA-487, or equivalent information, if applicable; • Flow sheets or treatment sheets, if used; • Narrative or progress notes, if used; • Supplemental order, if applicable; • Itemized breakdown of supplies, if supplies are billed; • Lab values, if applicable; • Copy of the UB-92 for each bill; • Lab reports for any B12 injections; • Lab or x-ray reports for any calcimar injection; • Other __________________________________________ The above information should be mailed to the following address within 30 days from the date of this letter: Intermediary Name, Address, and Contact Person Our medical review staff will review the documentation you submit for each of the claims to determine if the services billed are reasonable and necessary and meet all other requirements for Medicare coverage. Along with our claims payment determination, we will make a limitation on liability decision for services that are subject to the provisions of §1879 of the Social Security Act (the Act), and a determination in accordance with §1870 of the Act (whether you are without fault for any overpayments). We will project the overpayments identified in the sample to the universe of claims processed during the time frame described above. We will adjust the projected overpayment to reflect any previously denied claims which are payable, denied claims for which you were found not liable under §1879 of the Act, and denied claims for which you were found to be without fault under §1870 of the Act. Following our review, we will inform you in writing of our findings. We will provide you with a listing of the claims that were reviewed and our determinations with regard to those claims (i.e., full or partial denials and payable claims), the specific reasons for denial, identification of denials that fall under §1879 of the Act and those that do not, our liability determination for those denials that fall under §1879 of the Act, our determination of whether you are without fault under §1870 of the Act, an explanation of why you are responsible for the incorrect payment, the amount of the overpayment or underpayment, and interest accrual on unpaid balances. We will provide you with an explanation of your right to submit a rebuttal statement under 42 CFR 405.370-375 if we determine that you have been overpaid, and your options for repaying any overpayments, or our refund of any underpayments. We will provide you with an explanation of how any overpayment was determined, including the sampling methodology used to project the amount of the overpayment. We will also provide you with a full explanation of your appeal rights, including appeal of the sampling methodology used to determine the overpayment, estimation of the overpayment, coverage decisions, limitation on liability decisions under §1879 of the Act, and our determination as to whether you are without fault under §1870 of the Act. If you have any questions concerning this request, you may contact me at (telephone number). Your cooperation is appreciated. Sincerely, Enclosure: Listing of Sample Claims Requiring Medical Documentation