Reimbursing Providers and Health Information Handlers

3.2.3.6 - Reimbursing Providers and Health Information Handlers (HIHs) for Additional Documentation (Rev.: 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) A. General 1. Rules for MACs, SMRC, CERT, and UPICs • The MACs, SMRC, CERT, and UPICs are not required to pay for medical documentation for either prepayment or post payment review. 2. Rules for RACs • RACs performing post payment review of hospital inpatient prospective payment system (PPS) and long-term care facilities are required to pay the providers for submitting requested medical records. RACs shall pay according to the payment rate schedule listed in section B below. • RACs performing post-payment review of provider types other than hospital inpatient PPS and long-term care facilities are required to pay the providers for submitting requested medical records, according to the payment rate schedule listed in section B below. • Providers under a Medicare reimbursement system (such as Critical Access Hospitals) receive no reimbursement for submitting medical records. • RACs shall pay a maximum of $15.00 per record, including first class postage if applicable, for requested documents submitted via mail/fax/CD/DVD. • RACs shall pay a maximum of $27.00 per record, including a transaction fee of $2.00/case, for requested documents submitted via esMD. • Payments will not be made for blank pages or documents/records that are not related to the claim being reviewed. • RACs shall issue documentation submission payments on at least a monthly basis and shall issue all photocopying payments within 45 calendar days of receiving the documentation. RACs shall honor all requests from providers to issue photocopying payments to HIHs. RACs should gather, from the provider, all necessary information, such as, the HIH’s name, phone number and bank routing number, etc. • Providers interested in submitting documentation via esMD can find information on the CMS esMD website at http://www.cms.gov/esMD. B. Payment Schedule for Requested Medical Records Hospital Inpatient Prospective Payment System (PPS) Facilities and Long Term Care Facilities Non-PPS Institutions and Practitioners Documentation sent via mail, fax, CD/DVD - 12 cents per page - Plus first class postage, if applicable - $15.00 maximum per record - 15 cents per page - Plus first class postage, if applicable - $15.00 maximum per record Documentation sent via esMD - 12 cents per page - Plus $2.00 transaction fee, per record - $27.00 maximum per record - 15 cents per page - Plus $2.00 transaction fee, per case - $27.00 maximum per record *Note: Providers under a Medicare reimbursement system (such as Critical Access Hospitals) receive no reimbursement for submitting medical records. Also, payments will not be made for blank pages or documents/records that are not related to the claim being reviewed.