Postpay Provider Specific Medical Record Review

7.2.2.12 - Postpay Provider Specific Medical Record Review (Rev. 721, Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17) Medical record review requires a licensed medical professional to use clinical review judgment to evaluate medical records. Provider specific postpay medical record review of claims requires that a benefit category review, statutory exclusion review, and/or reasonable and necessary review be made after claim payment directed at an individual provider. This includes requests for, collection and evaluation of medical records or any other documentation. The review is as a result of vulnerabilities determined by data analysis and identified in the Medical Review strategy. The failure of the provider to submit documentation shall result in a denial. Contractors shall use Group Code: CO - Contractual Obligation and Claim Adjustment Reason Code (CARC) 50 - these are non- covered services because this is not deemed a “medical necessity” by the payer and Remittance Advice Remark Code (RARC) M127 - Missing patient medical record for this service. For the purpose of calculating and reporting MR workload, cost and savings, this is postpay medical record review and is not to be counted as a probe review.