Medical Review Part A Fact Sheet
Published 01/21/2020
Medical Review Department
For questions about Medical Review, please call the Provider Contact Center (PCC).
Diagnosis Coding
The following sources may be helpful for issues related to diagnosis coding. For CMS computer based diagnosis training, visit www.ahima.org. For the American Hospital Association Coding Clinic for diagnosis, visit www.ahacentraloffice.org.
Additional Documentation Requests (ADRs)
An ADR is a request from Palmetto GBA for copies of medical records for review purposes:
- A provider has 45 days to respond and submit documentation for review
- ADRs are available in eServices
- ADRs are mailed in white Palmetto GBA envelopes
- Submit the requested documentation to the address on the ADR using the appropriate mail code
- It is suggested that the provider track an ADR from the time it is received/printed until the agency receives a Remittance Advice
- Using the DDE system, the provider may monitor which claim(s) are in the ADR status/location SB6001
- To print a hardcopy ADR from DDE, select 01 'inquiries" and press enter. Select 12 for "Claims" at the sub-menu. Press enter. Tab to the S/LOC field and type SB6001. All claims in this S/LOC will be reflected in the "Claim Summary Inquiry" screen.
- Following medical review, if there is a difference on the Remittance Advice between the submitted charges and the agency’s payment, the provider can access the Remarks section to determine the reason for any denials/down codes of claims. At the DDE Main Menu, select 02. Press Enter. Select 26 and press enter. Enter page number "04" and press enter. Medical Review remarks are located on page 04. If a review note is not available on this page, contact the Provider Contact Center for assistance.
Comprehensive Error Rate Testing (CERT)
The CERT contractor is an independent CMS contractor and not part of Palmetto GBA. You can visit CMS' website. Also, visit the CERT link on the Palmetto GBA website for articles including:
The CERT contractor is an independent CMS contractor and not part of Palmetto GBA. You can visit CMS' website. Also, visit the CERT link on the Palmetto GBA website for articles including:
- The ABCs of the Comprehensive Error Rate Testing (CERT) Program and How to Respond to CERT Requests
- Comprehensive Error Rate Testing (CERT) Teaching and Instruction for Provider (TIP) Letters from Medical Review
- Comprehensive Error Rate Testing (CERT) Fact Sheet and Flowchart
CMS Online Manuals
Visit CMS.gov and select Publication 100-02, Medicare Benefit Policy Manual for coverage issues. For billing issues, select Publication 100-04, Medicare Claims Processing Manual.
Visit CMS.gov and select Publication 100-02, Medicare Benefit Policy Manual for coverage issues. For billing issues, select Publication 100-04, Medicare Claims Processing Manual.