Recovery Audit Contractor (RAC) Program
Frequently Asked Questions
What are the various review types and how do they differ?1
There are three categories of reviews – Automated, Semi-automated, and Complex
Automated
No medical records are requested or reviewed. Discovery is done through data-mining. There is clear and
unambiguous CMS policy that supports the results as an overpayment/underpayment. There is no Review
Results Letter sent to the Provider. The Recovery Auditor (RA) submits the corresponding adjustment to the
Medicare Administrative Contractor (MAC or Payer), and once the MAC has setup that claim for adjustment,
the Provider can view that claim on Connolly’s Provider Portal.
Semi-automated
No medical records are requested or reviewed. Discovery is done through data-mining. The difference,
however, is that the semi-automated reviews are used where “a clear CMS policy does not exist but in most
instances the items and services as billed would be clinically unlikely or not consistent with evidence-based
medical literature.” Therefore, the RA sends an Informational Letter to the Provider subsequent to the
review and it details the findings. The Provider has the option to submit documentation which they believe
provides additional information to support the correct billing of the claim. The Informational Letter is not an
Additional Documentation Request (ADR). If the Provider chooses to submit documentation to the RA, they
have 45 days to do so. If the RA does not receive any additional documentation, the adjustment is submitted
to the MAC.
Complex
Claims are selected for review, and the RA sends an ADR to the Provider. The Provider has 45 days to
respond to the ADR. When the documentation is received, the RA has 60 days to conduct the review. If the
documentation is not received within 45 days, the RA makes one good faith effort to follow-up with the
Provider. If no documentation is subsequently received, the full amount of the claim is sent to the MAC for
adjustment. This is considered a technical denial. Subsequent to a Complex review, the Provider will
generally receive one of three letter types from Connolly:
Review Results Letter: The review is complete, and there was an overpayment or underpayment
finding. This letter gives the Provider a detailed rationale to support the finding, the amount of the
impending adjustment, and what the Provider can anticipate in terms of next steps.
No Findings Letter: Confirms that the review has been completed, and there were no findings. No
adjustments will be sent to the MAC pertaining to that review.
Non-receipt Letter: This is confirmation the claim has been technically denied due to non-receipt of
the requested documentation. The claim will be sent to the MAC for full adjustment.
Does CMS approve all audit concepts?1
Yes, CMS not only has to pre-approve what is being audited (the specific concept) they also have to approve whether
that concept is appropriate for an Automated, Semi-automated, or Complex review type.
1
This information is taken from the Recovery Auditor Statement of Work found at www.CMS.gov. This information is
subject to change/update at any time, and the above information is current as of the date on this document.
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FAQ04232015
Updated: 4.24.2015