Existing Wording: Payers review select medical claims and associated medical documentation to ensure the services billed were medical necessary and in compliance with Payer rules. Such reviews safeguard the Payers programs by measuring, identifying and preventing improper payments. To gather information necessary to complete a review, the Payer may request the patients medical record from the provider.

When requesting documentation, the payer must specify the claim and member (patient) details including PHI. Therefore, both the secure channel used to send the request and the destination to which the request is being sent need to be agreed upon by the Payer and Provider in advance.

Proposed Wording: Payers review select medical claims and associated medical documentation to ensure the services billed were medical necessary and in compliance with Payer rules. Such reviews safeguard the Payers programs by measuring, identifying and preventing improper payments. To gather information necessary to complete a review, the Payer may request the patients medical record from the provider.

When requesting documentation, the payer must specify the claim and member (patient) details including PHI. Therefore, both the secure O13+O13channel used to send the request and the destination to which the request is being sent need to be agreed upon by the Payer and Provider in advance.

Comment:

This content is duplicated in this section. Remove one occurance.

Summary:

This content is duplicated in this section. Remove one occurance.