Prepay Provider Specific Medical Record Review

7.2.2.5 - Prepay 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. 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. If the requested documentation is not received, the review is not considered medical record review. 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, contractors shall count these denials as automated reviews or non-medical record reviews depending on the method of development.