RACs may use automated review (where NO medical record is involved in the review) ONLY in situations where there is certainty that the claim contains an overpayment.
Automated review must:
How will RACs review claims for overpayments and underpayments?
- have clear policy that serves as the basis for the overpayment (“clear policy” means a statute, regulation, National Coverage Determination, coverage provision in an interpretive manual, or Local Coverage Determination that specifies the circumstances under which a service will ALWAYS be considered an overpayment);
- be based on a medically unbelievable service; or
- occur when no timely response is received in response to a medical record request letter.
RACs will use complex review in cases where there is a high degree of probability but not certainty that an overpayment exists. Whenever needed for reviews, the RAC may obtain medical records by going onsite to the provider’s location to view/copy the records or by requesting that the provider mail/fax or securely transmit the records to the RAC.
