US · guidance
CMS Pub. 100-08, ch. 7, § 7.2.2.5
Prepay Provider Specific Medical Record Review
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.
History
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
8dd24cccabe692966bbc011ab7479eb6ff73d75de52071493f9f3f0e1b69214f
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.