Complex Reviews

In this type of review, there will be a request for medical records. Records can be mailed, faxed or sent on a CD/DVD. Mailed records must be sent in a tamper-proof package, and should be sent via trackable carriers (FedEx, UPS, Registered USPS.) Multiple records may be sent in one package if each record set is in a separate envelope inside the package.

Providers have 45 days plus 10 mailing days for a total of 55 days to send the records, but the RACs are permitted to grant an extension if contacted in a timely manner. Failure to communicate with your RAC about problems you are encountering in sending the records could result in an automatic recoupment of the related claim.

Once a RAC receives the medical records and a determination has been made, they will send the provider a Review Results Letter which will detail the findings. If the provider disagrees with the RAC determination, they may contact the RAC and discuss the findings and/or provide additional information. If after discussion you still disagree with the RAC determination, you may elect to file an appeal with the respective claims processing contractor. For automated review determinations, this discussion period takes place after provider receipt of the overpayment demand letter.  Appeals must be filed within 120 days of the receipt of the demand letter from the RAC.

The Pollen Line is now closed. See you in the spring!

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