Electronic Submission of Medical Documentation

As you know, CMS has employed several types of Review Contractors to review and recoup improper payments each year. The Contractor’s role is to review, measure, prevent, identify, and correct any improperly paid claims. This is done by selecting a sample of claims, requesting medical documentation from the provider who submitted the claims, and manually reviewing the claims against the medical documentation to verify the provider’s compliance with CMS rules.

The documentation is currently requested by sending a paper letter to the provider and the provider has two options for submitting the requested records – mail paper or send a fax.

CMS intends to give providers a new mechanism for submitting medical documentation. They are calling this mechanism Electronic Submission of Medical Documentation (esMD). During Phase 1 of implementation, the Review Contractors will continue to send medical documentation requests via paper and provider will have the option to electronically send medical documentation to the Review Contractor that requested it. CMS esMD Gateway went live on September 15, 2011.

Several Review Contractors have already been APPROVED to participate in the esMD pilot effective September 2011:

·         Recovery Audit Contractor (RAC) A

·         RAC B

·         Medicare Administrative Contractor (MAC) J1

·         MAC J3

·         MAC J4

·         MAC J5

·         MAC J9

·         MAC J11

·         MAC J12

·         MAC J13

·         MAC J14

·         Comprehensive Error Rate Testing (CERT) Contractor

·         Program Error Rate Measurement (PERM) Contractor

·         DME MAC A

·         DME MAC B

·         DME MAC D

Look for more Review Contractors to be added as the program progresses.

For more information, search CMS’ website: www.cms.gov