Submit Medical Records and Itemized Bills Before Requested

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1. Review the last 12 months of remits, filtered to review only the original remit for each encounter.
2. Filter the list to look at only CARC 252 where RARC Code 1 = M127_Missing patient medical record for this service, or N706_Missing Documentation.
3. If you receive a remit that meets either of those criteria, we recommend that you immediately send the Medical Records or Itemized bill to the payer. Include the request record.
4. If you are not staffed to accommodate these requests, we recommend partnering with a release of information vendor to promptly facilitate the release of records
5. To proactively manage these requests, we recommend you work with your data analyst team and look for patterns in your data. For example, examine the last 12 months of original remits, and for inpatient encounters, study patterns around payers, DRG’s and Total Charges.
6. If you see a pattern, start by validating that the contract allows the payer to request medical records. Most states have clean claim statutes that help providers avoid having to send records and letters on clean claims.
7. If, however that language isn’t present, identify the criteria that trigger a request and apply them upstream,  so you can send the Medical Records or Itemized Bill around the same time as you submit the claim, eliminating the denial altogether.  
8. For outpatient encounters, look for patterns around procedure codes and Total Charges. Where you see patterns of denied claims, use the same criteria and apply them to your data before billing.
9. Ultimately, you will have a daily work segment that lets PFS billers identify accounts that need medical records or itemized bills with the initial claim submission. Billers may send the documentation to the claim electronically prior to submission through their respective claims vendor/clearinghouse, and/or print the claim on paper, enclose documentation,  and mail directly to the payer.

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