This applies to MACs, RACs, CERT, and ZPICs, as indicated.
esMD: Electronic Submission of Medical Documentation
MAC : Medicare Administrative Contractors
RAC : Recovery Audit Contractor
CERT: Comprehensive Error Rate Testing
ZPIC : Zone Program Integrity Contractor
A. Prepayment Review Time Frames
When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 30 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 45.
B. Postpayment Review Time Frames
When requesting documentation for postpayment review, the MAC, CERT and RAC shall notify providers that the requested documents are to be submitted within 45 calendar days of the request. ZPICS shall notify providers that requested documents are to be submitted within 30 calendar days of the request. Because there are no statutory provisions requiring that postpayment review of the documentation be completed within a certain timeframe, MACs, CERT, and ZPICs have the discretion to grant extensions to providers who need more time to comply with the request. The number of submission extensions and the number of days for each extension is solely within the discretion of the MACs, CERT and ZPICs. RACs shall follow the time requirements outlined in their SOW.
C. For esMD submissions
The esMD review contractor shall use the Content Transport Services receipt date as the date the documentation was received.
If the CTS receipt date is outside of the contractors normal business hours the following business day shall be used as the receipt date.
If unforeseeable circumstances occur, in which contractors are not technically capable of retrieving documentation due to issues outside of their control, contractors can use the date documentation was available to be retrieved once issues have been resolved in CTS.