How to Navigate the Medical Review Projects

Jurisdiction 11 Home Health and Hospice

FAQs: Additional Medical Review Projects and CERT

To help reduce the Comprehensive Error Rate Testing (CERT) program error rates, Palmetto GBA was recently funded by CMS to undertake additional medical review projects that involve medical review of and education for certain E/M coded claims, advanced imaging claims, major procedure claims, inpatient hospital claims and home health claims that contributed to the majority of the J11 MAC CERT payment errors. Providers selected for education and/or medical review are selected based on the frequency of their billings for the services/codes mentioned above.

Palmetto GBA’s educational and review efforts will primarily focused on reducing payment errors from insufficient documentation and improper coding. Providers will receive written results of the project’s findings if being selected for medical review

The following FAQs are developed to help clarify what the additional medical reviews involve and how providers can help in the process. For more information, please refer to the article The ABCs of the Comprehensive Error Rate Testing (CERT) Program and How to Respond to CERT Requests.

1.            Will the reviews be done on claims that have already paid? Claims review is focused on prepayment review at this time; however, post payment review will be initiated if necessary.

2.            Who will be selected for review and/or education for the additional medical review projects? All providers who bill the identified codes may be included in the review projects.

3.            Did I do something wrong to be included in this small sample review? Not necessarily. Providers were selected on the basis of their utilization of certain procedure codes. Being selected for review does not necessarily that a provider has done anything wrong.

4.            How will I know what claims have been selected for review? Providers will receive additional documentation requests (ADR letters) requiring medical records for each claim. The ADR will state the claims were selected as a result of a “special study” or “increased medical review.”

5.            How much time do I have to submit the requested documentation? It is important to provide the requested documentation within 30 days. If no documentation is received by our office within 30 days from the date noted on your ADR letter, the claim determination will be made based on the information present. Failure to respond to the documentation requests may result in further scrutiny by Palmetto GBA.

6.            How do I submit the requested documentation? Submit complete documentation as requested to the fax number or address located on the ADR letter. If you do not have the original ADR letter, please submit your documentation with the applicable fax cover sheet. Documentation for Part A claims should be faxed to (803) 462-2576. Documentation for Part B claims should be faxed to (803) 462-2577. Documentation for HHH claims should be faxed to (803) 462-2578.

7.            If I miss the deadline to submit the requested documentation, can I just resubmit the claim? Claims that were denied due to lack of documentation cannot be resubmitted as a new claim. Resubmitting a denied claim as a new claim is considered fraudulent billing practice. If you miss the deadline for the documentation request and you receive a remittance advice indicating a denial due to missing information (remark code N102), you may submit the requested complete documentation along with a Redetermination and Reopening Request form located on the Palmetto GBA J11 Part A, J11 Part B and J11 Home Health and Hospice website.

8.            What can I do if I disagree with the medical review decision on a claim? If you disagree with a claim decision, you may request a redetermination within 120 days from the date of the remittance advice.

9.               How will I learn of the review results? Providers will receive results in writing once all of their selected claims have been reviewed and results have been calculated.

10.            What are some common reasons for claim denials?How can I avoid these denials? Some common reasons claim denials to occur are:

  • Missing or illegible provider signature or use of a signature stamp
  • Missing or unsigned physician’s orders
    • Verify that any necessary orders are legibly signed and submitted with the requested documentation.
  • Illegible documentation
    • Print or clearly write progress notes and all medical documentation if dictation is not used.
    • If you feel documentation may be deemed illegible, you may submit typed or dictated exact copies of any written documentation.  Make sure that any typed or dictated copies include the complete date of service and are signed legibly by the provider.
    • Ensure that documentation is clean and dark enough to be legible when received as a fax transmission.
  • Failure to provide documentation for all dates of service requested.
    • Review the ADR letters closely to ensure that documentation is submitted for all dates of service requested.

Learn More

For additional information regarding redeterminations, please refer to the Appeals section of the J11 Home Health and Hospice website.

For tips on Home Health Billing or more info regarding this article, contact Imark Consulting, Inc. or

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