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Response to RFP No. MED13002 State of West Virginia ... - DHHR

Response to RFP No. MED13002 State of West Virginia ... - DHHR

Record Request Reminder

Record Request Reminder Sample Notification Date: MM/DD/YYYY Provider Name: Provider TPI Attn: Provider Address City, State ZIP Subject: Record Request Reminder Notification Letter 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 reminder letter for the following: West Virginia Bureau For Medicaid Services XXXXXXXXX XXXX X-XXX-XXX-XXXX This is a request for the medical records and related documentation of the client named above. We are working with the West Virginia 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 West Virginia 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: West Virginia 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 West Virginia Bureau for Medical Services Audit at x-xxx-xxx-xxxx.

No Response Notification Sample Notification Date: MM/DD/YYYY Provider Name: Provider TPI Attn: Contact Name or Business Department Provider Address City, State ZIP Subject: No Response Notification West Virginia Bureau for Medical Services xxxxxxxxx xxxxxxxxx x-xxx-xxx-xxxx 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 Contact Name or Business Department: You failed to submit the records we requested from you on MM/DD/YYYY and reminder of record request on MM/DD/YYYY. This resulted in a technical denial of services rendered on dates of service from MM/DD/YYYY to MM/DD/YYYY. The records and documentation were requested under the authority of the Bureau for Medicaid Services (BMS) for the West Virginia 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). You have failed to supply the requested documents and other items within the time frame specified in our request for medical records; therefore, payments for all of the claims related to the missing records will be recouped. The adjustment will be processed on or after MM/DD/YYYY, and the amount deducted from future Medicaid reimbursements

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