CMS Pub. 100-08, ch. 7, § 7.2.2.13

Medical record review requires a licensed medical professional to use clinical review

judgment to evaluate medical records. Service 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 a certain

service. 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, it is not considered a 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, this is postpay medical record review and is not to be counted as a probe review.

7.2.2.14 - Data Analysis

(Rev. 444, Issued: 12-14-12, Effective: 04- 01- 13 (FISS and MCS); 07-01-13 (VMS);

Implementation: April 1, 2013 (Implementation of FISS and MCS); July 1, 2013

(Implementation of VMS)

Used to identify and verify potential errors to produce the greatest protection for the

Medicare program. Data analysis is an essential first step in determining whether

patterns of claims submission and payment indicate potential problems. It includes

simple identification of aberrancies in billing patterns within a homogeneous group, or

much more sophisticated detection of patterns within claims or groups of claims that

might suggest improper billing or payment. Data analysis is undertaken as a part of

general surveillance and review of submitted claims, conducted in response to

information about specific problems stemming from complaints, provider or beneficiary

input, fraud alerts, reports from CMS, other ACs, MACs, or independent government and

nongovernmental agencies.

Background The Contractor uses CERT findings, internal and external data sources,

review of claims, and information from other operational areas to

identify patterns of erroneous billing submissions and areas of over

utilization to target provider-specific review.