decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Medicare_Carriers_Manual / 14021 / 14021
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Article Overview
This article covers Medicare carrier recordkeeping guidance for potential fraud or abuse matters, including what information should be documented in complaint files and how unresolved cases should be maintained. It is relevant to Medicare program integrity staff, reviewers, and others responsible for managing complaint records and case documentation. The material focuses on administrative documentation, retention expectations, and file organization rather than clinical coding.
Why This Topic Matters
Accurate retention and organization of fraud-or-abuse complaint records supports later review, follow-up, and internal oversight within Medicare operations.
Article Sections
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Ed. Note: For further information see
A short editorial note pointing readers to related material on records kept for settled cases.
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14021. RECORDKEEPING
General instructions for maintaining records related to potential fraud or abuse situations, including retention expectations and documentation for complaints and unresolved cases.
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Cases Resolved
Guidance on documenting matters that can be closed without referral when possible and preserving information for later review.
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Source of Complaint
Information to record about the person or organization that reported the concern, along with identifying details for the provider involved.
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Nature of Complaint
The type of complaint information to summarize, along with dates and a brief account of how the matter was closed.
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Complaints Not Immediately Resolved
Instructions for maintaining separate case files and retaining supporting documents for matters that remain open or require further review.
What You Will Learn
- How Medicare carrier records should be maintained for suspected fraud or abuse matters.
- What categories of case information are documented in complaint files.
- How unresolved cases are organized for later review.
- What kinds of supporting documents are kept in case files.
Who Should Read This
- Medicare carrier staff
- program integrity personnel
- compliance staff
- reviewers and auditors
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