CMS Pub. 100-08, ch. 3, § 3.8

This section applies to MACs and Recovery Auditors. UPICs refer to the

PIM chapter 4.

A. General

When a disaster occurs, whether natural or man-made, MACs and Recovery Auditors

shall anticipate both an increased demand for emergency and other health care services,

and a corresponding disruption to normal health care delivery systems and networks. In

disaster situations, MACs should do whatever they can to ensure that all Medicare

beneficiaries have access to the emergency or urgent care they need. MACs are

encouraged to let providers know (via Web site, responses to provider calls, etc.) that the

provider's first responsibility, as in any emergency, is to provide the needed emergency or

urgent service or treatment. The MACs should assure providers they will work with

providers to ensure that they receive payment for all covered services. The administrative

flexibility available to MACs and Recovery Auditors is discussed below. These actions

will prevent most inappropriate denials and subsequent appeals.

B. Definition of Disaster

A disaster is defined as any natural or man-made catastrophe (such as hurricane, tornado,

earthquake, volcanic eruption, mudslide, snowstorm, tsunami, terrorist attack, bombing,

fire, flood, or explosion) which causes damage of sufficient severity and magnitude to

partially or completely destroy medical records and associated documentation that could

be requested by the MACs and Recovery Auditors in the course of a Medicare audit,

interrupt normal mail service (including US Postal delivery, overnight parcel delivery

services, etc.), and/or otherwise significantly limit the provider's daily operations.

A disaster may be widespread and impact multiple structures (e.g., a regional flood) or

isolated and impact a single site only (e.g., water main failure). The fact that a provider is

located in a presidentially declared disaster area under the power of the Stafford Act is

not sufficient in itself to justify administrative relief, as not all structures in the disaster

area may have been subject to the same amount of damage. Damage must be of sufficient

severity and extent to compromise retrieval of medical documentation.

C. Basis for Providing Administrative Relief

In the event of a disaster, MACs and Recovery Auditors shall grant temporary

administrative relief to any affected providers for up to 6 months (or longer with good

cause). Administrative relief is to be granted to providers on a case-by-case basis in

accordance with the following guidelines:

• The MACs and Recovery Auditors shall make every effort to be

responsive to providers who are victims of the disaster and whose

medical documentation may be partially or completely destroyed.

• Providers must maintain and submit verification upon contractor

request by the MAC or Recovery Auditor that (1) a disaster has

occurred and (2) medical record loss resulted from this disaster to

the point where administrative relief from medical review

requirements is necessary to allow the provider sufficient time to

retrieve copies of, or restore damaged, medical documentation.

Verification of the disaster and the resultant damage should include but is not limited to:

(1) Copies of claims filed by the provider with his/her insurance and

liability company; and

(2) Copies of police reports filed to report the damage, (3) copies of claims

submitted to FEMA for financial assistance, (4) copies of tax reports

filed to report the losses, or (5) photographs of damage. MACs and

Recovery Auditors shall not routinely request providers to submit

verification of damage or loss of medical record documentation.

D. Types of Relief

Providers Directly Affected By Disaster

The MACs and Recovery Auditors shall stop sending ADR letters to providers who have

been directly affected for at least 60 calendar days. The MACs and Recovery Auditors

shall allow up to an additional six months beyond the original due date for the submission

of requested records. Requests for extensions beyond this date can be granted with good

cause at the discretion of the MAC or Recovery Auditor.

In the case of complete destruction of medical records where no backup records exist,

MACs and Recovery Auditors shall accept an attestation that no medical records exist

and consider the services covered and correctly coded. In the case of partial destruction,

MACs and Recovery Auditors should instruct providers to reconstruct the records as

much as possible with whatever original records can be salvaged. Providers should note

on the face sheet of the completely or partially reconstructed medical record: "This record

was reconstructed because of disaster."

Providers Indirectly Affected By Disaster

For providers that are indirectly affected by a disaster (e.g., an interruption of mail

service caused by a grounding of US commercial air flights), MACs and Recovery

Auditors shall take the following actions:

For ADRs, extend the parameter that triggers denial for non-receipt of medical records

from 45 calendar days to 90 calendar days. ADRs shall reflect that the response is due in

90 calendar days rather than 45 calendar days. This action will prevent most

inappropriate denials and unnecessary increases in appeals workload.

If the MAC or Recovery Auditor receives the requested documentation after a denial has

been issued but within a reasonable number of days beyond the denial date, the MAC or

Recovery Auditor has the discretion to reopen the claim and make a medical review

determination. Many reviewers follow a standard 15 calendar days although MACs and

Recovery Auditors shall make these decisions on a case-by-case basis. The MACs and

Recovery Auditors shall allocate the workload, costs and savings to the appropriate MR

activity.

The MACs and Recovery Auditors shall review reopened claims retroactively to the date

of the disaster. The MAC’s data analyses shall take into consideration the expected

increase in certain services in disaster areas.

E. Impact on MAC Performance Evaluations

During performance evaluations, CMS will consider a waiver to all MAC MR

requirements, as necessary, to allow MACs the flexibility to handle issues that arise in the

aftermath of a disaster. Examples of such waived requirements include workload targets

and any other MR administrative rules. MACs shall retain documentation of how their

MR operations were affected during the disaster and make it available to Performance

Evaluation Teams and other CMS Staff, upon request.