Review Results Informational Letter Cotiviti

Review results informational letter cotiviti

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Region 4 Recovery Audit Contractor (RAC)
Review Results - Informational Letter
Dear Medicare Provider,
The Centers for Medicare & Medicaid Services (CMS) has retained Cotiviti GOV Services (Cotiviti RAC 4),
formerly HMS Federal (HMS) to carry out the Recovery Audit Contracting (RAC) program in Region 4. The
RAC program is mandated by Congress and supported by SSA §1893(f)(7) and SSA §1893(h)(1) and (3), has a
primary goal of identifying Medicare improper payments. Improper payments include overpayments and
underpayments. Improper payments may occur because of incorrect coding, lack of sufficient
documentation or no documentation, use of an outdated fee schedule or billing for services that do not
meet Medicare’s coverage and/or medical necessity criteria etc

Your Right to Disagree
If you disagree with our findings, you have the option to submit our Discussion Request Form, which must
include evidence to support why you believe the services you provided are covered by Medicare and were
properly coded and correctly billed

• If the additional documentation you provide substantiates a change in our original finding, a review
outcome letter will be sent providing the outcome of our review

• You have thirty (30) days from the date of this Review Results Letter, which is also the date of the
Provider Portal notification, to submit the Discussion Period Request in writing. If you require an
extension, for submission of the Discussion Period Request please contact us

• During this period, or during our review of your Discussion Period Request, Cotiviti RAC 4 will not
submit the claim(s) for adjustments to your Medicare Administrative Contractor (MAC). After that
period expires, the claim(s) identified as improper will be shared with your MAC and they will issue a
Demand Letter outlining your appeal rights and repayment options

• You can find the updated Discussion Request Form including submission instructions at – including how a Physician or a Physician who is employed by your
facility, not a consultant, may request to speak with Cotiviti RAC 4’s Medical Director. You may also
track the status of your Discussion Period Request via the Provider Portal

This letter is to notify you that Cotiviti RAC 4 believes that Medicare has potentially made an improper
payment to you. A description of the claims associated with the improper payment can be found on the
attached Audit Detail page. Data analysis shows that the claims paid by Medicare include a potential
aberrant billing pattern for the reasons listed on the attached Audit Detail

RAC 4 RAC 4 Address (877) 350-7993
Page 1
FRVW-LetterRef# 150395-2
The results of our data analysis justified reopening your claim under §1869(b) (1) (G) of the Social Security
Act and 42 CFR 405.980(a) (1). These results also serve as good cause to reopen the claim, if required by
42 CFR 405.980(b) (2), and 42 CFR 405.986,
Based on the billing guidelines reviewed for the selected claim(s) Cotiviti RAC 4 found that some of the
services you submitted were not reasonable and necessary as required by §1861 of the Act, or did not
meet the Medicare coverage requirements as required in §1862 of the Act outlined in the attached Audit
Detail page. Along with our claims payment determination, we have made limitations on liability decisions
for denials of those services subject to provisions of SSA §1814, SSA 1833(e), and SSA §1835, SSA 1866 (a)
(1)(A)(i)(42 USC 1395cc §1879 of the Act). Those claims for which we determined that you knew, or should
have known, that the services were noncovered have been included in the results of this review. In
addition, we have made decisions as to whether or not you are without fault for the overpayment under
the provisions of §1870 of the Act. Those claims for which you are not without fault have been included in
the results of this review. Pursuant to 42 CFR 405.982 and 42 CFR 405.984 detailed information regarding
each claim and the findings identified during the review are attached to this letter

Discussion Period: If you believe that this improper payment determination was made in error, you may
submit a request for a discussion period to support the billed services. The information must be
submitted to Cotiviti RAC 4 at the below referenced fax number or address within thirty (30) days of the
date of this letter. You may track the status of your Discussion Period Request at

Cotiviti GOV Services (Cotiviti RAC 4)
Attention: Discussion Period Review
RAC 4 Address
Fax: (702) 240-5510
Please submit a copy of the Audit Detail page along with your supporting documentation for each claim

The Discussion Period begins with the Review Results Letter for a complex medical record review or with
the Informational Letter date for an automated review. The discussion period is the opportunity to submit
a statement and accompanying evidence to the RAC indicating why the adjustment should not be initiated

A physician (or a physician employed by the provider) may also submit a request to discuss an improper
payment finding with RAC Contractor Medical Director within thirty (30) days from the date of this letter

The request may be submitted via fax at (702) 240-5510, via direct upload to the provider portal at or by contacting a Provider Relations Representative at (877) 350-7993. The
outcome of the discussion process could change how or if the claim will be submitted for adjustment. The
RAC will advise you of its decision in writing. Please include a copy of the discussion form for each claim,
along with your supporting documentation. The Discussion Form is located at

To ensure that the request is received and processed timely we encourage you to submit the discussion
period request immediately upon receipt of this letter. Do not bundle or submit comingled records for
multiple claims/audits in one transmission

RAC 4 RAC 4 Address (877) 350-7993
Page 2
FRVW-LetterRef# 150395-2
If the discussion period request is not received within thirty (30) days from the date of this letter, or if the
RAC determines that the submitted documentation does not support the billed service(s), the claim will be
submitted to your Medicare Administrative Contractor (MAC) for adjustment. Per CMS’ directive, the RAC is
not required to accept discussion period request received on or after the thirty-first (31st) day of this letter
and cannot accept discussion period request after the claim has been submitted to the MAC for processing

A demand letter will follow which identifies the overpayment amount and outlines repayment options as
well as appeal rights. Do not submit refund checks to the RACs. Refund checks for RAC identified improper
payments should not be sent to the RAC or the MAC upon receipt of an Informational Letter for an
automated review, Review Results Letter for a complex review or the Discussion Period Review outcome
letter. Instead, Providers should wait to receive a demand letter, from the MAC, which identifies the
improper payment amount and outlines repayment options

Notice: "Good Cause” Language: Why Cotiviti RAC 4 Selected These Claims
Pursuant to applicable Medicare reopening regulations, including without limitation the Medicare Claims
Processing Manual, Ch.34, §10.6.1 and Ch. 3, §3.5.1, the claims noted on the attached Audit Detail were
selected for review for an underpayment or overpayment, as applicable, for the following reasons:
1. There is New and Material Evidence that was not available or known at the time of the
determination or decision and may result in a different conclusion; and
2. The evidence that was considered in making the determination or decision clearly shows on its
face that an Obvious Error was made at the time of the determination or decision

New and Material Evidence and Obvious Error made at the time of the initial determination include:
a. Improper or incorrect application of Medicare billing or coding requirements;
b. The medical or other necessary records associated with the claim were not reviewed prior to the
initial determination, a coverage or coding determination based upon the information on the claim
and its attachments could not be made and there is a high probability that the records do not
support the services paid or the service is not covered, and copies of medical records are therefore
needed to provide support for the claim; and
c. At the time of the initial determination, data analysis techniques, editing and/or review processes
were not applied to the claim

Cotiviti RAC 4 has reviewed the claims noted on the attached Audit Detail. In accordance with CMS
regulations, Cotiviti RAC 4 data analysis techniques coupled with periodic OIG Reports
(;,, quarterly PEPPER Reports (The Program for Evaluating Payment Patterns
Electronic Report, see, National and Local Coverage Determinations
(NCD/LCD), Coding Clinic, CPT, CPT Assistant, DRG Expert, and National Correct Coding Initiatives Edits
(NCCI) resources do not support the services paid, the services would therefore not be covered, and a
billing or coding error therefore exists

RAC 4 RAC 4 Address (877) 350-7993
Page 3
FRVW-LetterRef# 150395-2
Thank you for your cooperation and prompt attention to this improper payment. If you have any questions
regarding this letter, would like to check the status of the discussion period review or discuss the improper
payment identification, please direct your inquiry to Provider Relations

Email: [email protected] (Do not include PHI)
Phone: (877) 350-7993
Fax: (702) 240-5510
Mail: RAC 4 Address
Cotiviti GOV Services (Cotiviti RAC 4)
RAC 4 RAC 4 Address (877) 350-7993
Page 4
FRVW-LetterRef# 150395-2

The Discussion Period begins with the Review Results Letter for a complex medical record review or with the Informational Letter date for an automated review. The discussion period is the …

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