Revenue Cycle

Q&A: Medical records request

Recovery Auditor Report, October 30, 2008

Question: Under what circumstances can a RAC make a finding that an overpayment or underpayment exists without requesting medical records?

Answer: RACs may use automated review (where no medical record is involved in the review) only in situations where there is certainty that the claim contains an overpayment. Automated review must:

  • Have clear policy that serves as the basis for the overpayment (“clear policy” means a statute, regulation, National Coverage Determination, coverage provision in an interpretive manual, or Local Coverage Determination that specifies the circumstances under which a service will always be considered an overpayment);
  • Be based on a medically unbelievable service; or
  • Occur when no timely response is received in response to a medical record request letter.

Source: Centers for Medicare & Medicaid Services.

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