FAQ Table of Contents

RAC Contacts
General Process
Timeline
Correspondence
Medical Records
Audit Review
Information for PIP Providers

RAC Contacts

Question: Who are the DCS contacts for provider staff?
Answer:

• DCS Customer Service Department at 1-866-201-0580
• Email Info@dcsrac.com
• Fax Number 325-224-6710

General Process

Question: What states are in DCS’ Region A?
Answer: Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

Question: What states are included in the Region A MAC Jurisdictions (J12, J13 & J14)?
Answer: The MAC Jurisdictions are as follows: J12 - DC, MD, DE, PA, NJ; J13 - NY, CT; J14 - NH, VT, ME, MA, RI.

Question: How do I obtain a user id and password to access the “Claims Status” page?
Answer: The user id and password for access to that page will be sent with the 1^st ADR letter. Only providers who have received an ADR letter will have a user id and password assigned. If you have received an ADR letter and have not received a user id and password, please contact Customer Service.

Question:  I have been unable to access DCS website and log into "claim status", error page cannot be displayed. What can I do?
Answer:  Please call our Customer Service office at 1-866-201-0580.  They are available to help you with your access into the “claim status” site.  (new)

Question: Where are DCS customer service staff located?
Answer: DCS customer service staff are located in Texas.

Question: Does DCS use a subcontractor? If so, who is the subcontractor, and does DCS or CMS have oversight of the subcontractor?
Answer: DCS does utilize subcontractors. These subcontractors include iHealth Technologies and PRGX. DCS does provide direct oversight of the subcontractors.

Question: What procedure does DCS plan to utilize to coordinate payment take backs with the MACs? Will the take backs appear on a separate voucher that clearly identifies they are the result of a Recovery Audit Contractor (RAC) audit?
Answer: The process will be the same as it currently is with your MAC. The MAC will notify the provider by submitting a remittance advice prior to recoupment stating that the adjustment is RAC related and will have a remittance advice code N432.

Question: Will DCS begin with smaller batch sizes in order to acclimate both DCS and the provider to the RAC process?
Answer: The batch sizes will depend on the type of the case. However, DCS will work with the providers to ensure that we do not overwhelm them.

Question: How will DCS communicate with providers and provider associations regarding issues that have been identified?
Answer: Once CMS approves an issue for review, DCS will place the issue on the DCS Web site. Providers should check the http://www.dcsrac.com regularly to see all issues that have been approved by CMS and are being audited by the RAC.

Question: How often will DCS staff provide update forums either in person, via audio conference, or Web conference?
Answer: DCS may provide periodic conference calls/webinars. However, the primary source of information should always be the DCS Web site.

Question: Will DCS review only Medicare Fee for Service (FFS) claims or will you also review Medicare Advantage claims?
Answer: DCS will only review Medicare FFS claims.

Question: Will PRGX be focusing on home health/hospice only, or are there other areas they will be responsible for?
Answer: PRGX will conduct Part A and Part B audits in MAC Jurisdiction 14 and home health/hospice audits in all states in Region A.

Question: Will DCS be sending correspondence to providers for all audits, or will some come from PRG Schulz?
Answer: PRGX will send some correspondence to providers but the letterhead will be DCS' and all correspondence will be signed as DCS.

Question: How will the RAC escalate issues that customer service representatives cannot resolve?
Answer: RAC customer service representatives have an escalation process to answer questions and address issues as efficiently as possible by the best qualified person. This will, of course, include the involvement of the Contractor Medical Director (CMD).

Question: Does DCS have enough qualified staff (i.e.: medical director, coders, RNs, etc.)? For example, if a case pertains to hematology or pediatrics, will the individual reviewing the case have the same background?
Answer: DCS has a pool of qualified staff with many years of experience working as auditors/medical reviewers. Our CMD will be very involved in the process including determining what issues we should review, training our staff, and overseeing reviews. Nurses will be utilized for medical necessity complex reviews. Coding reviews will be performed by certified coders that are CCS, CPC, RHIA, or RHIT certified. The CMD will be involved in QA of reviews and will have access to 35 specialty physicians.

Question: If I am a chain provider whose FI is WPS (Wisconsin Physicians Service)(serving as the national fiscal intermediary) who will my RAC be?
Answer: This answer assumes the hospital originally had Mutual of Omaha as the claims processing contractor and the merger of WPS and Mutual of Omaha is how WPS became the provider's claim processing contractor. WPS currently serves as a national fiscal intermediary for CMS. They service providers in the majority of the states. These providers have not yet transitioned to a MAC. WPS will work with all 4 RACs. If WPS is your claim processing contractor (as the national fiscal intermediary and not part of the local jurisdiction) your RAC is based on your physical location. For example, if you are located in Region A, but WPS is your claims processing contractor your RAC is in Region A.

Question: During the "discussion period", if a record is discussed and agreement is reached that the provider is correct, will the provider receive a letter to that effect?
Answer: If and when it is decided during the discussion period that the provider is correct, then DCS will notify the MAC of the decision. If the provider requests a letter stating the new results of the review, DCS will generate a letter stating the decision.

Question: If I opened a discussion with the RAC can I also file an appeal?
Answer: The provider may appeal however, once an appeal has been filed with the MAC, the RAC will close the discussion period. 

Question: Please clarify the procedure that a provider may follow if they disagree with the DCS determination and wish to discuss the account with DCS concerning the denial? (Discussion Period)
Answer: The RAC discussion period begins with receipt of the review results letter for complex reviews or the demand letter for automated reviews. If a provider has any questions after receiving a letter they should contact DCS immediately to ask questions. The discussion period continues until the issue is resolved or recoupment is complete. This period is for the provider to contact DCS via telephone or written inquiry using the discussion form , and provide additional information they feel may support their original claim or request clarification from DCS as to why the denial was issued.

Question: If a provider is in the discussion period with the RAC, is the appeal still due on day 31? What are the exact details and rules we must follow in regard to rebutting a decision during the "discussion period"?
Answer: Yes the appeal is still due on day 31. Although the discussion period falls into the time frame when the provider can file an appeal, it is distinctly separate from the appeals process. We would encourage the providers to contact DCS shortly after receiving the Review Results Letter or Demand Letter and discuss the issue/issues they may have.

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Timeline

Question: When will DCS have their web-based status system operational for providers?
Answer: January 2010.

Question: What is the contract duration between DCS and CMS?
Answer: The contract duration is five (5) years.

Question: What happens if the recovery auditor does not meet the 60 day requirement?
Answer: The recovery auditors have 60 days from receipt of the medical records to make a determination and issue a written notice of that determination to providers. The 60 day requirement can be found in the Statement of Work used in the Recovery Audit Program. Lack of adherence to the 60 day requirement of notification does not negate the improper payment finding or the recoupment of the improper payment by CMS. Lack of adherence to the 60 day requirement is a performance issue between CMS and the recovery auditor.  (new)

Question: How are the 30 days utilized, business days or calendar days?
Answer:  The RAC utilizes calendar days to meet required time frames. (new)

Question: What period of time will the RAC work on? Will they work from 10/1/2007 forward or will they begin by reviewing current charts.
Answer: DCS will conduct analysis on data received from CMS. Based on this analysis DCS will determine which claims to audit. DCS may "look back" up to 3 years to review claims. However, RACs may not review claims prior to October 1, 2007.

Question:  When reviews have gone past the 45 days. How can we as the provider be able to verify if the records past the 45 day review timeline have been appropriately extended by CMS?
Answer:  DCS has 60 days to complete complex reviews.  The provider has 45 days to mail records to DCS when they have received a additional documentation request (ADR). (new)

Question: How long will the provider have the Review Results Letter before the Demand Letter will be issued?
Answer: There are a few factors into this timetable.  (1) DCS will make every effort to forward the claim to the MAC at the same time the Review Results Letter is sent out.  (2) Once the MAC has created the appropriate Accounts Receivable, they will inform DCS.  (3) The MAC is responsible for sending the Demand Letter as soon as possible.  If you have any questions about the Demand Letter please contact the MAC.   (updated)

Correspondence

Question: How will DCS obtain provider contact information? If a provider is part of a larger system of providers, and the system staff will be coordinating the RAC activities, how will DCS adapt their processes to accommodate this?
Answer: DCS will accept customized provider contact information from the provider via our Web page, telephone, mail, email or fax. Additionally, we will accept updated contact information provided by the provider associations.

Question: How will DCS send Additional Documentation Requests, Review Result Letters, and other letters? (updated)
Answer: DCS will follow CMS' requirements to send all communication using first class mail as opposed to private carriers. DCS is prohibited from sending Protected Health Information (PHI) in an electronic format.

Question: How many letters will the Provider receive from DCS?
Answer: The Provider may receive two letters from DCS, 1) Additional Documentation Requests (request for medical record) and 2) Review Results Letter from DCS for the Complex review.  For Automated reviews and Complex reviews, the Provider will receive the Demand Letter from the MAC.  (updated) 

Question: Will the providers receive individual demand letters for each account or will letters list multiple accounts for complex and automated reviews?
Answer: The MAC is responsible for sending the Demand Letter as of January 3, 2012.  Please contact them for more information about the letter.  (updated)

Question: Will the RAC be assigning a claim number for each review or will a unique batch ID be generated by the auditor for each request and maintained through all future correspondence?
Answer: There is no batch ID generated by DCS on correspondence. DCS references the Medicare claim number in letters. The DCS Letter also contains a HIC number, beneficiary name, letter id, and date of service. (updated)

Question: Is a Detailed Review Results letter the same as a Overpayment Demand letter?
Answer:  No, a Review Result letter is sent prior to the Overpayment Demand Letter for a Complex review.  The Review Results Letter explains the findings of the review and explains Discussion Period options.  The Overpayment Demand Letter is generated by the MAC.  It provides the address where you need to send your payment, and the Centers for Medicare and Medicaid Services (CMS) regulatory appeal, rebuttal, and overpayment recoupment information. (updated)

Question:  If the provider has been reviewed by the Contractor Error Rate Testing (CERT), Office of Inspector General (OIG) or Department of Justice (DOJ), etc. for a specific claim and the issue has been settled or the investigation is still in process. Can the RAC also review and initiate a recoupment on those claims?
Answer:  CMS and the RACs utilize the RAC Data Warehouse as the central repository for all RAC reviewed claims.  Certain Medicare partners (e.g., OIG, DOJ, FBI, claims processing contractors, CERT contractor, etc.) are able to access the Data Warehouse and effect suppression and/or exclusion actions.  These actions temporarily or permanently prevent a RAC from reviewing all or part of a universe of claims for a specific provider or claim type. (new)

Question:  Is there a document that defines the differences in MAC vs. RAC in terms of discussion /rebuttal periods timeframes, appeal time frames, etc?
Answer:  The objectives of the Medicare Administrative Contractors (MAC) and the Recovery Audit Contractors (RAC) are addressed in their respective CMS Statement of Work (SOW).  The RAC SOW is posted on the CMS RAC Web site (www.cms.gov/rac).  Essentially, the RACs detect and correct improper payments in the Medicare FFS program through post payment review.  The RACs are required to comply with all CMS contractual, statutory and regulatory authorities when performing reviews and making determinations.  This includes all provisions and timeframes reflected in the Social Security Act, Code of Federal Regulations, and local and national coverage policies.  The MACs implement actions that will prevent future improper payments (e.g., pre-pay review of Medicare claims), focus on preparer review and provider education.  (new) 

Question:  Will DCS or National Government Services be issuing informational reports to summarize types and rates of denials and appeal outcomes?
Answer:  CMS releases an annual report to Congress that is released in the new calendar year and available to the public.  It is a high level report which includes information that you may find useful.  (new)

Question:  Will the Recovery Audit Contractors (RAC) appeal process mirror the regular Medicare appeal process?
Answer: The Medicare Appeals process will remain the same for physicians under Part B and Part A non-inpatient claims. The only difference under Part A is for the inpatient hospital claims under the Prospective Payment System (PPS). In the current appeals process, the first level appeal will go to the Quality Improvement Organization (QIO); however, the RAC appeals will go to the Fiscal Intermediary that processed the claim.  (new)

Question: If during the preparation process (reviewing and preparing to forward records to the Recovery Auditor based on an Additional Documentation Request letter) if we find a coding error; should we rebill at that point? (updated)
Answer:  No, Rebilling will not eliminate an audit.  Once a claim has been selected, records should be submitted as requested for audit completion.  You will be notified of the results and if a difference in reimbursement has been identified.  

Question: Will there be any correspondence sent for complex review cases where the RAC auditor agrees with the original billing of the claim?
Answer: Yes, review results letters are sent on cases that the RAC agrees with the original billing of the claim.

Question:  What if the Provider received an Automated Review Audit Notice Letter or an Underpayment Notification Letter but has not received a Demand Letter?
Answer:  The MAC is responsible for sending the Demand Letter as of January 3, 2012.  If the provider has received an Automated Review Audit Notice Letter or an Underpayment Notification Letter from DCS this means that DCS was notified that the MAC has created an appropriate Accounts Receivable.  Please contact your MAC to discuss why you have not received a Demand Letter.  (new)



Question:  What if the Provider received a Demand Letter at a different address then what they placed on the DCSRAC website, or the address provided to the DCS Customer Service Team?
Answer: The MAC is responsible for sending the Demand Letter as of January 3, 2012 and uses the address they have on file for this claim.  DCS cannot update the provider address at the MAC.  If you want the address changed for Demand Letters please contact the MAC.  DCS does still send the Additional Documentation Request letters and we will utilize the address you have provided us to mail those.  (new)

Question:  If I have questions about how my claim was adjusted and I don't think the amount requested back is correct, who do i call?
Answer:  You will need to discuss your concerns with your MAC as they are responsible for making all financial adjustments (Overpayments and Underpayments).  If you are in HMS Jurisdiction 12, please call 877-235-8073.  If you are in NGS Jurisdiction 13, please call 877-567-7205 or if you are in NHIC Jurisdiction 14, please call 866-590-6731.  (new)

Question:  I still haven't received my Demand letter?  What do I do?
Answer:  As of January 3, 2012, the MACs are responsible for mailing Demand letters.  DCS will provide the AR date on the provider claim status page to alert providers to expect a Demand Letter from the MAC.  If you feel that enough time has passed and you still have not received a letter and you are in HMS Jurisdiction 12, please call 877-235-8073.  If you are in NGS Jurisdiction 13, please call 877-567-7205 or if you are in NHIC Jurisdication 14, please call 866-590-6731.  (new)

Question: Where can I go to request immediate offset?
Answer: Please refer to the appropriate MAC website listed below:
NGS - http://www.ngsmedicare.com/wps/wcm/connect/facb9e0044661732a74fbf7c289de06c/MMR_2010_3.pdf?
MOD=AJPERES&CACHEID=facb9e0044661732a74fbf7c289de06c&LOB=Part+A&REGION=&clearcookie=&savecookie
NHIC - http://www.medicarenhic.com/dme/forms/offsetrequest.pdf
Novitas - https://www.novitas-solutions.com/bulletins/partb/news02092009.html


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Medical Records

Question: What is the maximum number of records that DCS may request from a provider at any given time? Is the limit based on NPI or TIN?
Answer: We realize that this issue has caused a lot of concern for providers. CMS is currently in the process of providing updated instructions/guidance on the medical records limits. Please see the CMS Web site (www.cms.gov/RAC) for medical record information.

Question: Once a provider receives an additional documentation request from DCS, how long will they have to respond?
Answer: A provider has 45 days (plus 10 days for mailing) to provide medical records to DCS. If you need additional time, please contact DCS customer service.

Question: Will the RAC be allowing providers to supply electronic transmission at any point? If a provider uses an electronic medical records system, what documentation will they be required to provide to DCS?
Answer: For providers with electronic medical records system the same information is required as when submitting a paper record.  Currently, submission of PHI via paper, fax, CD/DVD, or transmission via electronic submission of Medical Records (esMD) are allowed.  Other forms of submission are not available.  More information about esMD can be found on the following CMS information web page: https://www.cms.gov/ESMD/. (updated 1/31/2012)

Question: Will DCS request complete records, specific items from records, or both?
Answer: DCS will request both specific items and the complete record and ask the provider to submit any documentation they feel supports their claim.

Question: Is there a process for sending a single piece of information during DCS' review/discussion period?
Answer: Yes, you may use the discussion period form which may be faxed or mailed to DCS, or you may contact customer service via telephone.

Question: Is the cost for medical record copies reimbursed and does that include medical records on CD/DVD? Will we need to invoice the RAC for the number of pages copied per review?
Answer: DCS will reimburse $.12 per page plus first class postage for medical record copies for IPPS facilities and LTC facilities. This includes medical records on CD/DVD. DCS utilizes a system that tracks the number of pages of medical records scanned (paper) or imported (CD) into the system so the provider does not need to invoice the RAC.

Question: How many medical records can be on one CD/DVD?
Answer: As many as can fit on the CD/DVD.

Question:   Being that we can fit many medical record requests onto a CD or DVD, My concern is that if the disc is lost, the fewer records on the disc the better. Is there a limit to how many files that should be put on one disc?
Answer:  There is no limit; however, we would like you to fit as many medical records as you can on one CD or DVD.  The process we recommend you use for sending CDs or DVDs is designed to ensure the information on your CD or DVD will be secure but we would suggest that you make a copy for yourself.  (new)

Question: How will the provider be notified by the RAC of the calculated chart limit per 45 days per NPI?
Answer: The medical record limit will be included on the medical record request form.

Question: Which imaging company is DCS affiliated with or endorse?
Answer: DCS is not affiliated with and does not endorse any imaging company.

Question: Is there particular software that is recommended for creating CD/DVDs in Region A?
Answer: No. The providers may use any kind of CD/DVD writing software that they choose.

Question: Does CMS have a standard encryption process or is this the decision of each healthcare organization?
Answer: Each healthcare provider may decide how or if they want to encrypt their medical records. CMS recommends that some sort of electronic protection is used but that is up to the provider.

Question: Instead of being dependent on United State Postal Services (USPS) and the mailrooms for delivery of the Additional Documentation Request (ADR) letters, would DCS consider emailing them or giving an electronic access to the letters on their Web site?
Answer: Medicare requires DCS to send these letters via first class mail. Additionally, DCS cannot email them or provide Internet access to them due to CMS' security requirements.

Audit Review

Question: If DCS denies a hospitals claims for services, will they also deny the physician claims for services?
Answer: Currently, there is no such "automatic cross-over". It is possible that referencing between hospital and physician claims may occur in the future. Any action that would involve denying physicians' claims would have to be approved as a separate issue by CMS.

Question: If DCS were to extrapolate error results, how would it work and what types of claim errors would be extrapolated?
Answer: Although extrapolation is permitted in the RAC Statement of Work (SOW), DCS does not intend to use extrapolation, at least initially. If DCS chooses to extrapolate, we would request approval from CMS and follow the instructions in the Medicare Program Integrity Manual.

Question: If DCS requests a medical record for review and then is not able to review it within the 60 days, can they re-request the same record?
Answer: No, If DCS is not able to complete a review within 60 days, DCS may request an extension from CMS. CMS may or may not grant the extension. However, neither CMS nor DCS expects to miss the 60 day time period. 

Question:  Is it required that we send the physician query form if it is not an approved part of the medical record?
Answer:  Providers can submit a physician query form.  However, the medical record must stand alone.  The query form may serve for clarification only.  (new)  

Question: Which utilization criteria will DCS use to review medical necessity; Interqual, Milliman or another?
Answer: DCS will use only Medicare's legal and regulatory documents and policies, such as National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), as guidelines for decision making. We may also choose to utilize clinical support software products as screening tools. If such products are used, the information about this choice will be made available to the community.

Question: What will DCS accept from the provider when supporting a medical necessity denial? If the provider has their own algorithm for medical necessity can this be used to support the decision?
Answer: The provider may submit their algorithms and reasoning supporting the medical necessity, and DCS will review these, but the clinical staff will base their decisions on the patient's clinical situation against the background of Medicare's rules and regulations.

Question: Will DCS accept missing (additional) documents during the discussion period?
Answer: Providers should provide all documentation to support a case when the medical record is originally sent. If a circumstance arises where all documentation is not sent with the original record, then the provider may submit this during the discussion period for review at the RACs discretion.

Question: If we have any question regarding any aspect of the appeals process who should we contact?
Answer: DCS will not handle appeals. Providers should follow the same process for appeals they currently follow with their MAC. Any appeal related questions should be directed to the MAC.

Question: Can multiple accounts (denied for the same reason) be appealed using one appeal letter or are individual letters required?
Answer: DCS will not handle appeals. Providers should follow the same process for appeals they currently follow with their MAC. Any appeal related questions should be directed to the MAC.

Question: Can we send additional information at the first level of appeals/any level of appeal? If a provider appeals, and the appeal is denied, is a letter sent explaining why?
Answer: DCS will not handle appeals. Providers should follow the same process for appeals they currently follow with their MAC. Any appeal related questions should be directed to the MAC.

Question: What is considered non-compliance by the ordering physician with regard to supplying medical documentation?
Answer: Any failure to respond to a request from CMS for documentation that supports the charges on a claim would be considered non-compliance. §1833 (e) of the SSA, and 42 CFR 424.5(a)(6) prohibit Medicare payment for any claim that lacks the necessary information to determine whether payment is due and the amount of payment.

Question: With regard to medical documentation, what is the provider's extent of responsibility for supplying documentation? Example - The ordering physician telephones an order for DME to the supplier and then faxes a written prescription, but neglects to supply medical records, despite numerous attempts on the part of the supplier.
Answer: The supplier who bills Medicare and receives payment is responsible for providing the documentation.

Question: Will DCS consider reviewing underpayments for DRG's? If they are re-coded to a higher DRG than what the provider was paid, will this be sent as an underpayment?
Answer: Yes.

Question: Due to confusion and continually changing policies, how will the RAC auditors be aware of the dates policies were amended, as well as implementation dates of interim policies, memos and related correspondence?
Answer: The Recovery Audit Contractor (RAC) must abide by the Medicare legal and regulatory documents that were in effect at the time when the services were provided, to include the correct version of the Local Coverage Determination (LCD) by the Medicare contractor who had jurisdiction. The RAC must diligently research this regulatory backup and cite the correct authorities. If providers feel that a document was not considered or that an incorrect policy was invoked, they should bring this to the RAC's attention during the discussion period.

Question: What specific documentation is the supplier required to maintain within their company files with regard to the KX modifier?
Answer: The KX modifier states: "Specific required documentation on file." There are numerous Local Coverage Determinations that further define this. As a general rule, the information in the medical documentation must support the medical necessity by Medicare's criteria for the services rendered.

Question:  If a Diagnosis Related Group (DRG) is downcoded to a lower DRG after review, do we have to rebill for payment of the lower DRG.
Answer:   No, the MAC will make adjustments as appropriate and you will be notified of any difference in reimbursement.  (new)

 Question:  Will the Medical Necessity audits for Maryland be performed differently than other states?
 Answer:  No.  Medical Necessity audits are performed using the same medical criteria for every state to determine if the patient meets criteria for inpatient admission. (new)

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Information for PIP Providers

Question:  PIP Hospitals - Hospitals do not receive notification of a recoupment if a cost report is closed.  Have you looked into implementing a notification requirement before significant review of PIP hospitals begin?
Answer: CMS is implementing the new automated process which is included in CR 7601.  The HIGLAS system, which will be the automated CMS accounting systmes next year, will create receivables and generate demand letters for the PIP payments.  With this automated system, Recovery Auditors will not have to wait until the cost report is closed, and will not need to send notifications. 

Question:  PIP hospitals will receive notifications of all RA recoupment regardless of the status of the cost report, since the HIGLAS system will generate the Demand Letters.  Is that correct?
Answer: That is correct. 

Question:  What is PIP?
Answer: Periodic Interim Payments (PIP) are biweekly payments made to a Provider enrolled in the PIP program, and are based on the hospital's estimate of applicable Medicare reimbursement for the current cost report period.  Further details may be found at 42 CFR 413.64(h). 

Question:  Are claim audits from PIP providers different from other RA claim audits?
Answer: Improperly paid claims audited from a PIP provider do not differ from any other RA audit.  The claim identified as improperly paid would be shared with the claim processing contractor and adjusted as appropriate. 

Question:  What is the appeal process for PIP providers?
Answer:  The current appeal process does not change, and the timelines still apply.  Please see the Remittance Advice (R/A) for any applicable appeal rights or contact the appropriate claim processing contractor. 


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