Subject: Test Claim Sample Additional Documentation Request Date

Page 1 of 4Region A Recovery Audit Contractor (RAC)Subject: Test Claim Sample Additional Documentation RequestDate [Request Date]Letter Request ID: [Letter Request ID][RAC Point of Contact][Physisian Practice Name][Street Address Line 1][Street Address Line 2][City, State, Zip]Re: [Provider Name] [Provider NPI]The Centers for Medicare & Medicaid Services (CMS) has retained DCS to carry out theRecovery Audit Contractor (RAC) program in Region A which includes all states located in thenortheast region of the United States. The RAC program, mandated by Congress, is aimed atidentifying Medicare improper payments.This notice is to request documentation for the claim(s) listed in the attachment. Data analysisindicates potentially incorrect billing for [Describe the type and nature of the review asapproved by the CMS New Issue Review board, as well as the specific justification for theadditional documentation request. If appropriate, include a statement that your analysis hasestablished good cause for reopening. For example: …the medical necessity of cerumenremoval in this patient. Our analysis of your Medicare billing history, which suggests that youhave consistently submitted claims for this service well in excess of that which couldreasonably be expected of a Family Practitioner), constitutes new and material evidence thatestablishes good cause for reopening as required under 42 CFR 405.980(b).]This documentation is being requested because [----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------……………………………………...Description of issue………………………………………… ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------]DCS, INC. Continued on Reverse 866 201-0580 TOLL FREE2815 Southwest Boulevard 325-224-6710 FAXSan Angelo, TX. 76904www.dcsrac.comDCS

Page 2 of 4As mandated by the RAC Statement of Work (SOW), no improper payments may be recovereduntil CMS has approved the complex review audit concept associated with a certain claim(s).(RAC) is requesting additional documentation on this claim(s) as part of a test claim sample.The purpose of requesting the sample of claims is to assist the RAC and CMS in determining ifthe audit concept is consistent with Medicare policy. You will receive a Review Results Letterwith in 60 days from receipt of medical records advising you of the claim determination.However, these claims will not be sent to your claims processor for adjustment unless CMS hasapproved the complex review audit concept. If (RAC) determines that the review of these claimshas resulted in an improper payment, but CMS has denied the audit concept, (RAC) will notinitiate recovery on these claims, and (RAC) will send an additional letter notifying you that theiraudit for those claims has been closed.The results of our data analysis justified reopening your claim(s) under §1869(b) (1) (G) of theSocial Security Act and 42 CFR 405.980(a) (1). These results also serve as good cause to reopenthe claim(s), if required by 42 CFR 405.980(b) (2).In accordance with 42 USC 1320(c) (5) (A) (3) and §1833 of the Social Security Act, you mustprovide documentation upon request to support claims for Medicare services. This request is incompliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule,which allows release of information without explicit patient consent for treatment, payment andhealth care operations. All documentation should be submitted to the address or fax numberbelow within 45 days of the date of this notice. Your response is required even if you are unableto locate the requested documentation.This (these) claims will count towards your medical records request limits. CMS has establisheda maximum number of medical records that can be requested from a provider per 45 day period.This cap is established per campus. A campus unit, which is defined by the servicingprovider’s/supplier’s Tax Identification Number (TIN) and the first three positions of the zipcode where they are physically located, may consist of one or more separate facilities/practicesunder a single organizational umbrella. Each limit is based on that unit’s submitted Medicareclaims, irrespective of paid/denied status and/or individual lines in 2008. The maximum numberof medical records that may be requested from you per 45 days is [----number---------]All documentation should be submitted to the address or fax number below within 45 days of thedate of this notice. Your response is required even if you are unable to locate the requesteddocumentation.[Insert only for inpatient hospital claims that qualify for copying reimbursement] You will bereimbursed for the cost of providing copies of the additional documentation. Payment will beissued to you within 45 days of the RAC receiving the additional documentation. Payment willbe in the amount of _____ cents per page plus first class postage (if mailed).A copy of this request letter should be affixed to the requested additional documentation. Pleasebundle documents for each claim separately to enable us to confirm receipt of documents.DCS, INC. Continued on Reverse 866 201-0580 TOLL FREE2815 Southwest Boulevard 325-224-6710 FAXSan Angelo, TX. 76904www.dcsrac.comDCS

Page 3 of 4You may submit this documentation by postal mail (either on paper or as images on CD/DVD)or via fax. Documentation can be mailed to:DCS2815 Southwest BoulevardSan Angelo, TX 76904Documentation can be faxed to: 325-224-6710.Questions regarding this request should be directed to DCS RAC Region A Customer Service at1-866-201-0580.If you choose to password protect the CD/DVD please use password: th!s!smyp@$$w0rd.Requirements for submitting imaged documentation on CD or DVD can be found athttp://www.dcsrac.com/documentation.htmlPlease submit the following components of the medical record, as applicable, and/or any otherdocumentation to support payment of this claim.Face sheetPhysician progress notesDischarge summaryLaboratory reportsHistory & PhysicalRadiology reportsEmergency Room recordsOperative reportsAll nursing notesPathology reportsER nursing notesICD-9-CM codes submittedConsultationsPhysician queryPhysician orders UB 04 or HCFA (CMS) 1500Therapy Treatment Plan and NotesMedication Administration RecordsWound Care ConsultsAncillary Services (Social work)Nutrition ConsultsSincerely,DCS Customer Service866-201-0580DCS, INC. Continued on Reverse 866 201-0580 TOLL FREE2815 Southwest Boulevard 325-224-6710 FAXSan Angelo, TX. 76904www.dcsrac.comDCS

Page 4 of 4Requested ClaimsIssue Description:Beneficiary Med Rec # Patient Ctl #Beneficiary Beneficiary DOBDOS DOSMedicare RAC Case IDNameHICFrom To Claim Number Pmt AmtSmith, John 1234567890A 11/11/1931 ABC1234567 XY1234567NN 1/6/2008 1/8/2008 501234567890 $10,141.66 900012345677Doe, Jane 1234567891A 11/11/1932 XYZ1234567 XZ1234567JW 4/7/2008 4/7/2008 401122334455 $23,514.72 900045677777Rodriquez, Jesus 1234567892A 11/11/1933 NNN1234567 YZ1234567FF 6/6/2008 6/6/2008 309988776655 $45,319.36 900054683245DCS, INC. Continued on Reverse 866 201-0580 TOLL FREE2815 Southwest Boulevard 325-224-6710 FAXSan Angelo, TX. 76904www.dcsrac.comDCS