Prepay Service Specific Medical Record Review

7.2.2.6 - Prepay Service 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. Service specific prepay medical review of claims requires that a medical review determination be made before claim payment directed at a certain service. It 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, contractors shall count these denials as automated review or non-medical record review depending on whether the denial is automated or requires manual intervention.