Medicare_Program_Integrity_Manual / 98

Why This Topic Matters

It clarifies what documentation contractors may request and how they should evaluate submitted records during medical review, while also addressing privacy-related limits on psychotherapy notes. The update affects provider documentation workflows, contractor review practices, and Medicare claim support processes.

Article Sections

1. Summary of Changes

   Overview of the transmittal, effective dates, and the manual section revised by the update.

2. Attachment - Business Requirements

   Administrative and implementation information associated with the change request, including background references and provider education notes.

3. General Information

   Background, policy context, and provider education references for the Medicare documentation request instruction.

4. Business Requirements

   Placeholder for implementation requirements and related operational material in the transmittal attachment.

5. Supporting Information and Possible Design Considerations

   Supplemental implementation notes covering instructions, design considerations, interfaces, workload impact, dependencies, and testing.

6. Schedule, Contacts, and Funding

   Effective dates, implementation timing, and contact information for the transmittal.

7. 3.4.1.2 - Additional Documentation Requests (ADR) During Prepayment or Postpayment MR

   Detailed procedures for Medicare contractor documentation requests during medical review, including billing provider, third party, and ordering provider development.

8. A. Development of Non-Lab Claims for Additional Documentation

   General handling of non-laboratory claim documentation requests and related review actions.

9. Billing Provider ADRs

   Requirements for requesting and processing documentation from the billing provider during review.

10. Third Party ADRs

    Requirements for seeking documentation from other entities involved in care when permitted by the review process.

11. B. Development of Lab Claims for Additional Documentation

    Documentation request procedures specific to targeted laboratory services.

12. Billing Provider ADRs

    Documentation request procedures for billing providers in the laboratory claim context.

13. Ordering Provider ADRs

    Conditions and procedures for seeking documentation from ordering providers in laboratory claim review.

14. C. Psychotherapy Notes

    Privacy-related guidance on psychotherapy notes and how supporting documentation is handled in medical review.