Requests for Medical Records from Medicare

You may receive requests for medical records from Medicare for a variety of reasons. Requests may also come from several different Medicare contractors. Record requests may be related to any of the following:

• Review of a Medicare contractor through the Comprehensive Error Rate Testing (CERT) program
• More information is required before the Medicare contractor can process the claim
• Review of a new physician or practitioner to ensure a good understanding of Medicare claim submission and documentation guidelines
• Review of an established physician or practitioner, before or after the claim is paid, based on analysis of data
• Investigation of a complaint alleging possible fraud or abuse of the Medicare program
• Review of services by the Recovery Audit Contractor (RAC)

In all cases, it is imperative that you return the records to the requesting entity within the time frame specified. It is also vital that you include all of the requested records. Before responding to the request, double-check to ensure that you have included all relevant information, such as:

• If the request is for a physician or nonphysician practitioner (NPP) visit include documentation for that encounter:
  • and the physician/NPP’s note refers to results of a lab or other diagnostic test, include the test results with the requested information
• If the physician or practitioner’s signature is not legible, provide a key and indicate whose signature appears in the records
• If the physician or practitioner uses abbreviations that are not common, provide a key
• If the patient signed an Advance Beneficiary Notice (ABN), include a copy with the requested records
• If the service is the physician’s interpretation of a diagnostic test, such as an EKG or x-ray, provide his or her complete interpretation and copies of the test results. Do not send original x-ray films or other original records.