These sample letters were created for illustrative purposes. If chosen as the Recovery Audit Contractor of, PRGX will consult with WestVirginia BMS for the content of the communication letters
Record Request Sample WestVirginia BMS XXXXXXXXX XXXX X-XXX-XXX-XXXX Notification Date: MM/DD/YYYY Provider Name: Provider TPI Attn: Provider Address City, State ZIP Subject: Record Request Client Name: ICN #: Date of Birth: Medical Record #: PCN #: Date of Service: Case ID: Concept Short Name: Last Name, First Name MM/DD/YYYY MM/DD/YYYY to MM/DD/YYYY Dear Director of Health Information Management: This is a request for the medical records and related documentation of the client named above. We are working with the WestVirginia Bureau for Medical Services Audit to review the medical records and documentation to determine whether provider payments were appropriate. We will inform you of the results of the review after it has been completed. The medical records and documentation are being requested under the authority of the WestVirginia Bureau for Medicaid Services Audit. As specified in your Medicaid provider enrollment agreement, “provider understands and agrees that payment for goods and services under this agreement is conditioned on the existence of all records required to be maintained under the Medicaid program, including all records necessary to fully disclose the extent and medical necessity of services provided, and the correctness of the claim amount paid. If provider fails to create, maintain, or produce such records in full accordance with this Agreement, provider acknowledges, agrees, and understands that the public monies paid the provider for the services are subject to 100% recoupment, and that the provider is ineligible for payment for the services either under this agreement or under any legal theory of equity.” It is your responsibility to obtain any additional supporting documentation that is held by third parties (e.g., hospitals, nursing homes). Providing the medical records of Medicaid clients is within the scope of your compliance with the Health Insurance Portability and Accountability Act (HIPAA). Please fax the requested documentation and a copy of this letter to x-xxx-xxx-xxxx or mail them to: WestVirginia Bureau for Medical Services Attn: xxxxx Please submit the medical records and related documentation to us by MM/DD/YYYY. A response is required whether or not the requested information is available to you. Thank you for your cooperation and prompt attention to this matter. If you have any questions, please contact the WestVirginia Bureau for Medical Services Audit at x-xxx-xxx-xxxx.