Welcome to the Performant Recovery Inc. Frequently Asked Questions
FAQ Table of Contents
Information for PIP Providers
Question: Who are the Performant Audit Contractors for provider staff?
• Performant Customer Service Department at 1-866-201-0580
• Email Info@Performantrac.com
• Fax Number 325-224-6710
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Question: What states are in CMS RAC Region 1?
Answer: There are twelve (11) states: Connecticut, Indiana, Kentucky, Michigan, Maine, Massachusetts, New Hampshire, New York, Ohio, Rhode Island and Vermont.
Question: What states are in CMS RAC Region 5?
Answer: All States are included in the National Contract.
Question: How do I obtain a user id and password to access the “Claims Status” page?
Answer: You must have received your first ADR Letter and a Welcome letter. The welcome letter will include your user id and password for access to the “Claims Status” page. Only providers who have received their Welcome letter will have a user id and password assigned. If you have not received this letter and have received ADR letters, please contact Customer Service at 1-866-201-0580.
Question: I have not been able to access the Performant's website and/or log into "Claim Status", page. What can I do?
Answer: Please call our Customer Service office at 1-866-201-0580. They are available to help you with your access into the “Claim Status” site.
Question: Where is the Performant Customer Service Staff located?
Answer: The Performant Customer Service Staff is located in San Angelo, Texas.
Question: What procedure does Performant plan to utilize to coordinate payment take-backs with the MACs? Will the take-backs appear on a separate voucher that identifies they are the result of a RAC audit?
Answer: The process will be the same currently administered by all the MAC’s. The MAC will notify the provider by submitting a remittance advice prior to recoupment stating that the adjustment is RAC related and will have a remittance advice code N432. Should you have any questions please contact Customer Service at 1-866-201-0580.
Question: How will Performant communicate with providers and provider associations regarding identified issues?
Answer: Once CMS approves an issue for review, Performant will place the issue on the Performant website. Providers should check the website https://www.performantrac.com/ regularly to see all issues approved by CMS.
Question: Does Performant have enough qualified staff (i.e.. medical director, coders, RNs, etc?
Answer: Performant has a pool of qualified clinical Nursing staff with many years of healthcare experience working as auditors/medical reviewers. The coding auditors will be performed by certified coders with CCS, CPC, RHIA, or RHIT certifications. Our Contractor Medical Director provides audit support and is available for peer-to-peer reviews.
Question: During the Discussion Period, if an audit is discussed and the decision is the provider’s favor, will the provider receive an updated letter?
Answer: Yes. Performant will generate a letter to the provider regardless of the outcome on every discussion period request filed.
Question: If I opened a discussion with the RAC Region 1 or Region 5, can I also file an appeal?
Answer: In the current process a Provider may file a Discussion Period during the first 30 days after the RRL is mailed. Providers may only file an appeal once a Demand Letter from the MAC has been received. We highly encourage the provider to open a Discussion Period first. If the audit is overturned at the Discussion level, your file will never be sent to the Medicare Administrative Contractor for the adjustment to be set up and the audit will then be closed.
Question: Please clarify the procedure a provider may follow if they disagree with Performant's denial in the audit and wish to discuss the results concerning the denial?
Answer: This is called a Discussion Period. The Discussion Period continues for 30 days from the date of the Review Results Letter, or the Initial Findings Letter. All Discussion Period Requests must be filed individually by claim on the Discussion Period request form.
Question: I just received an ADR but we filed bankruptcy. Am I excluded from audits?
Answer: Not Necessarily. If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, please contact your MAC immediately to notify them about the bankruptcy so that they may coordinate with the Recovery Auditor Contractor, CMS and Department of Justice to assure your situation is handled appropriately.
Question: What are the contracted time frames by which providers will be notified by the RAC of favorable and unfavorable decisions after audits?
Answer: Performant has 30 days to complete the review and send a decision letter.
Question: How are the 30 days calculated, business days or calendar days?
Answer: The RAC utilizes calendar days to meet required time frames. Calendar days include weekends and holidays.
Question: What is the "look back" period for RAC work?
Answer:Performant may "look back" up to 3 years to review claims from the claim paid date.
Question: How long will the provider have the Review Results Letter before the Demand Letter will be issued?
Answer: Performant will forward the adjustment to the MAC 30 days after the Review Results Letter/Initial Finding letter or after a Discussion Period has been resulted. Once the MAC has created the appropriate Accounts Receivable, they will initiate the Demand Letter. If you have any questions about the Demand Letter please contact your MAC or call Performant Customer Service at 1-866-201-0580.
Question: How will Performant obtain provider contact information? If a provider is part of a larger system of providers, and the system staff will be coordinating the RAC activities, how will Performant adapt their processes to accommodate this?
Answer: Performant receives provider address/contact information periodically from the MAC's and uploads this information into our system. We strongly recommend that you utilize the provider portal to customize your provider contact information via our web page.
Question: How will Performant Recovery send Additional Documentation Requests, Review Result Letters, and other letters?
Answer: Performant Recovery will follow CMS' requirements to send all communication using first class mail as opposed to private carriers. Performant Recovery is prohibited from sending Protected Health Information (PHI) in an electronic format.
Question: How many letters will the Provider receive from Performant Recovery?
Answer: The Provider may receive up to three letters from Performant, 1) Additional Documentation Request (request for medical records for complex reviews), 2) An Initial Finding Letter for automated reviews or a Review Results letter for Complex reviews, and 3) a Discussion Period Decision letter (if a discussion period request was filed).
Question: Will the providers receive individual demand letters for each account or will letters list multiple accounts for complex and automated reviews?
Answer: The MAC is responsible for sending the Demand Letter. Please contact your MAC for more information regarding demand letter format.
Question: Is a detailed Review Results letter the same as an Overpayment Demand letter?
Answer: No, a Review Result letter is sent prior to the Overpayment Demand Letter for an Automated or Complex review. The Review Results Letter explains the findings of the review and explains Discussion Period options. The Overpayment Demand Letter is generated by the MAC. It provides the address where you need to send your payment, and the Centers for Medicare and Medicaid Services (CMS) regulatory appeal, rebuttal, and overpayment recoupment information.
Question: If the provider has been reviewed by the Contractor Error Rate Testing (CERT), Office of Inspector General (OIG) or Department of Justice (DOJ), etc. for a specific claim and the issue has been settled or the investigation is still in process. Can the RA also review and initiate a recoupment on those claims?
Answer: No, certain Medicare partners (e.g.., OIG, DOJ, FBI, claims processing contractors, CERT contractor, etc.) are able to access the CMS Data Warehouse and suppress and/or excludes the claim(s). These actions temporarily or permanently prevent a RAC from reviewing all or part of a universe of claims for a specific provider or claim type. Should you happen to receive a claim that has already been pulled by another entity, please contact Customer Service at 866-201-0580.
Question: If during the preparation process (reviewing and preparing to forward records to the RAC based on an Additional Documentation Request (ADR) letter) and we (the provider) find a coding error, should we rebill at that point?
Answer: No, rebilling will not eliminate an audit. Once a claim has been selected, records should be submitted as requested for audit completion. You will be notified of the results and if a difference in reimbursement has been identified.
Question: Will there be any correspondence sent for complex review cases where the RAC auditor agrees with the original billing of the claim?
Answer: Yes, review results letters are sent on cases the RAC agrees with the original billing of the claim. These are called "No Findings" Letters.
Question: What if the Provider received an Automated Review Results Letter or an Underpayment Notification Letter but has not received a Demand Letter?
Answer: As of January 1, 2016 you will not receive a demand letter until after a 30 day holding period after the date of the Review Results Letter or until the Discussion Period has been resulted. If this period has lapsed please contact Customer Service at 866-201-0580.
Question: What if the Provider received a Demand Letter at a different address then what they placed on the Performant Recovery website, or the address provided to the Performant Recovery Customer Service Team?
Answer: The MAC is responsible for sending the Demand Letter and uses the address they have on file for this claim. Performant Recovery cannot update the provider address at the MAC. If you want the address changed for Demand Letters please contact the MAC. Performant Recovery still sends the Additional Documentation Request letters and will utilize the address provided to mail the provider correspondence.
Question: If I have questions about how my claim was adjusted and I don't think the amount requested back is correct, who do I call?
Answer: Please call Performant Customer Service at 866-201-0580, 8a.m. - 4:30p.m. EST
Question: Where can I go to request immediate offset?
Answer: Contact your Medicare Administrative Contractor (MAC).
Question: Once a provider receives an additional documentation request from Performant, how long will they have to respond?
Answer: A provider has 45 calendar days to provide medical records to Performant. Calendar days include weekends and holidays.
Question: Will Performant request complete records, specific items from records, or both?
Answer: Performant will request both specific items and the complete record and ask the provider to submit any documentation, such as clinical support notes to support the audited claim.
Question: Is there a process for sending a single piece of information during Performant review/discussion period?
Answer: Yes, you must use the discussion period form which may be faxed or mailed to Performant. The Fax Number is 325-224-6710
Question: Is there a limit to how many medical record files that should be put on one disk?
Answer: There is no limit; however, we would like you to fit as many medical records as you can on one CD or DVD. The process we recommend you use for sending CDs or DVDs is designed to ensure the information on your CD or DVD will be secure but we would suggest that you make a copy for yourself. We also recommend sending the records electronically through the CMS electronic submission of Medical Records Program (esMD). For more information on how to be set up for ESMD, go to www.cms.gov/esMD.
Question: How will the provider be notified by the RAC of the calculated ADR limit per 45 day cycle?
Answer: The ADR limits are calculated by CMS and provided to the RAC's. The RAC will post the medical record limit will be provided on the provider claim status portal webpage, and can be found on page 2 of the Additional Documentation Request.
Question: Is there particular software recommended for creating CD/DVDs?
Answer: No. The providers may use any kind of CD/DVD writing software they choose. Image format must be in either PDF or TIFF format (PDF is preferred). Do not password protect individual PDF files. Instead, zip all PDF's into a WinZip file and encrypt it.
Question: Instead of being dependent on the United State Postal Services (USPS) and the mailroom for delivery of the Additional Documentation Request (ADR) letters, would Performant consider emailing them or giving an electronic access to the letters on their Web site?
Answer: We do recognize this may be a more efficient method to communicate to the provider. However, due to CMS security requirements, email is not the approved mode of communication for the RAC. Currently, CMS requires RAC’s to send our letters via first class mail.
Question: What is the maximum number of records Performant may request from a provider at any given time? Is the limit based on NPI or TIN?
Answer: Please see the CMS website for medical record information. **Medical documents submitted to Performant for review under an Automated review are not computed into the limits sent for complex reviews.
Institutional ADR Limits
DME ADR Limits
Physician/Non-Physician ADR Limits
Question: Will the RAC allow providers to supply electronic transmission at any point? If a provider uses an electronic medical records system, what documentation will they be required to provide to Performant?
Answer: For providers with electronic medical records system the same information is required as when submitting a paper record. Currently, submission of PHI via paper, fax, CD/DVD, or transmission via electronic submission of Medical Records (esMD) is allowed. Other forms of submission are not available. More information about esMD can be found on the following CMS information web page: https://www.cms.gov/ESMD/. Please contact us if you are able to send medical records via ESMD to make arrangements.
Question: Is the cost for medical record copies reimbursed and does that include medical records on CD/DVD? Will we need to invoice the RAC for the number of pages copied per review?
Answer: Performant is required to reimburse providers for the submission of medical records in accordance with the current guidelines prescribed in the PIM section 22.214.171.124. Per CMS and the PIM guidelines, providers such as critical access hospitals and DMEPOS providers under the Medicare system receive no photocopy reimbursement. PPS(institutional providers) will receive 0.12 cents per page + 1st class postage and non-PPS providers receive 0.15 cents per page + 1st class postage. An additional $2 is added for esMD submissions in lieu of postage. The maximum payment to a provider per medical record shall not exceed $25. There is no need to invoice. Performant will track record submissions and issue a check within 45 days of the receipt of the record.
Question: Our facility utilizes a Health Information Handler for ADR submissions. We would prefer that the RAC issues payment directly to them. Is this a service that Performant offers?
Answer: No. We will pay the providers directly.
Question: If Performant were to extrapolate error results, how would it work and what types of claim errors would be extrapolated?
Answer: Currently we are not using extrapolation, but have been approved to perform this method of analytics. Appropriate communication will be provided on the Performant RAC website when we plan to perform this process.
Question: If Performant requests a medical record for review and then is not able to review it within the specified timeframe, can they re-request the same record?
Answer: No, if Performant is not able to complete a review within the specified timeframe, Performant may request an extension from CMS.
Question: Which utilization criteria will Performant use to review medical necessity; Interqual, Milliman or another?
Answer: Performant will use Medicare's legal and regulatory documents and policies such as National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), and ICDs as guidelines. We may also choose to utilize clinical support software products such as Interqual and Milliman as screening tools. If such products are used, the information about this choice will be made available to the community.
Question: Will Performant accept missing (additional) documents during the discussion period?
Answer: Providers should provide all appropriate and accurate documentation to support a case when the medical record is originally sent. If a circumstance arises where all documentation is not sent with the original record, then the provider may submit this during the discussion period for review at the RACs discretion.
Question: If we have any question regarding any aspect of the appeals process who should we contact?
Answer: Currently, Performant does not handle appeals. Providers should follow the same process for appeals they currently follow with their MAC. Any appeal related questions should be directed to the MAC.
Question: What is considered non-compliance by the ordering physician with regard to supplying medical documentation?
Answer: Any failure to respond to a request from CMS for documentation that supports the billed charges on a claim would be considered non-compliance under §1833 (e) of the SSA, and 42 CFR 424.5(a)(6), which prohibits Medicare payment for any claim that lacks the necessary information. If documentation for complex review is not supplied in the time period request, the claim will be adjusted for full denial.
Question: With regard to medical documentation, what is the provider's extent of responsibility for supplying documentation? Example - The ordering physician telephones an order for DME to the supplier and then faxes a written prescription, but neglects to supply medical records, despite numerous attempts on the part of the supplier.
Answer: The supplier who bills Medicare and receives payment is responsible for providing the documentation. Any failure to respond to a request from CMS for documentation that supports the charges on a claim would be considered non-compliance under §1833 (e) of the SSA, and 42 CFR 424.5(a)(6), which prohibits Medicare payment for any claim that lacks the necessary information. If documentation for complex review is not supplied in the time period request, the claim will be adjusted for full denial.
Question: Will Performant consider reviewing underpayments for DRG's? If they are re-coded to a higher DRG than what the provider was paid, will this be sent as an underpayment?
Answer: Yes and we have provide such adjustments.
Question: Due to confusion and continually changing Medicare policies, how will the RAC auditors be aware of the amended policies as well as implementation dates of interim policies, memos and related correspondence?
Answer: The Recovery Auditors (RAC) must abide by the Medicare legal and regulatory in effect at the time when the services were provided, to include the correct version of the Local Coverage Determination (LCD) by the Medicare contractor who had jurisdiction. The RAC must diligently research this regulatory backup and cite the correct authorities. If providers feel a document was not considered or an incorrect policy was invoked, they should bring this to the RAC's attention during the discussion period.
Question: If a Diagnosis Related Group (DRG) is down coded to a lower DRG after review, do we have to rebill for payment of the lower DRG.
Answer: No, the MAC will make adjustments as appropriate and you will be notified of any difference in reimbursement. Should you have questions, please contact your MAC.
Question: What types of reviews will Performant perform?
Answer: Performant is authorized by CMS to perform Complex and Automated Reviews. All approved issues are listed on our website under "Approved Issues".
Question: What is a Complex Review?
Answer: A complex review requests sections of the medical record and reviews them to make clinical determination and/or a coding validation. The specifics of each type of issue and what document is requested can be found on the Approved Issues description page and will be included in the additional documentation request letter.
Question: What is an Automated Review?
Answer: In an Automated Review, Performant performs analysis of the claims data, makes a determination; no medical documents are requested or reviewed. The provider will then receive an "Initial Findings Letter" that will explain the audit. At this point the provider can either agree with the audit finding or they will have 30 days from the date of the Initial Finding Letter to file a Discussion Period Request Form. Call Customer Service with any questions at 866-201-0580.