Frequently Asked Questions

FAQ Table
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What are the different types of letters that my facility will receive related to improper payments?The letters the Recovery Audit Contractor (RAC) issues varies by whether an improper payment has been identified by automated or complex review. For automated reviews, providers will receive an informational letter. For complex reviews, providers will receive a medical record request letter and a review results letter. In the event that the review results letter contains a notification of improper payment, a demand letter will then be issued by the Medicare Administrative Contractor (MAC).
What do I do when I receive an informational or review results letter?You first review the informational or review results letter and Medicare Regulation to understand the improper payment determination. If you disagree with the improper payment determination, you may elect to file a Discussion Period with the RAC. You have 30 days to submit discussion material and supporting documentation to the RAC for review from the informational letter date for automated reviews and review results letter date for complex reviews. We strongly urge providers to submit all supporting documentation or information relating to a Discussion Period to the RAC within 30 days from date of receipt of the Information or Review Results letter.
Who issues the notification letter on Underpayment improper payments?The RACs will issue the Underpayment Notification Letters.
Who do I contact if I have a question or concern on a RAC improper payment?You would contact your RAC. For Region 4 (Cotiviti), you would contact the appropriate Provider Service number: Part A (877) 350-7992, Part B (877) 350-7993
What types of improper payments are Cotiviti looking for? dddddddddddddddddCotiviti reviews the claims data it receives from CMS for both underpayments and overpayments in the Medicare fee-for-service program, including incorrect payment amounts, non-covered services, incorrectly coded services, and duplicate services.
What determines whether an automated or complex review is performed? The type of review is determined by the CMS New Issue Review Process. All new improper payment New Issue Concepts developed by the RAC must first be approved by CMS and posted on the RAC provider website prior to the RAC mailing correspondence to providers.
What if I do not agree with an underpayment improper payment finding?If you do not agree with an underpayment improper payment finding, please submit a copy of the Discussion Period Request Form along with any additional documentation to support why the underpayment finding is not valid. Upon receipt, Cotiviti will perform an independent review of the documentation. If the improper payment finding is upheld the claim will be submitted to the Medicare Administrative Contractor (MAC) for adjustment.
How long does Cotiviti have to review the records I have sent?In virtually all circumstances, Cotiviti will complete its reviews within 30 days. You will receive a notification of the review results for every complex review.
Will I be reimbursed for the cost of producing the medical records?The Recovery Auditor shall pay the provider for medical records in accordance with the current guidelines prescribed in the Program Integrity Manual (PIM) (currently located in section, unless otherwise directed by the CMS Contracting Office Representative (COR). (The current per page rate is: medical records photocopying costs at a rate of $.12 per page for reproduction of PPS provider records and $.15 per page for reproduction of non-PPS institutions and practitioner records, plus first class postage.) The amount per page will not exceed these rates. Providers (such as critical access hospitals) under a Medicare reimbursement system receive no photocopy reimbursement. CMS guidelines will include the amount per page, the maximum amount per medical records and the amount per transmission. It is possible there will be different amounts per page depending on if the submission is paper, CD, fax, or esMD. The maximum payment amount to a provider for medical records received for each claim via esMD will not exceed $25.00. The maximum payment amount to a provider for medical records, not received via esMD, for each claim will not exceed $15.00.
What are my options for sending medical records?Whenever needed for complex reviews, the Recovery Auditor 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 Recovery Auditor. (Securely transmit means sent in accordance with the CMS business systems security manual – e.g., mailed CD, MDCN line, through a clearinghouse, esMD transmittal.) Medical Records may be submitted via Electronic Submission of Medical Records (esMD): Information for submitting imaged documentation via esMD may be found at Selecting this image will open a new window . Providers may also send paper copies via first class U.S. mail, fax, imaging vendor or scanned images sent via an encrypted CD/DVD. (Cotiviti does not reimburse for the expense of courier services such as FedEx or UPS. Any records sent using such courier services is at the expense of the provider)
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