In an automated review by FFS Recovery Auditors, what is required?

In an automated review by Fee-for-Service (FFS) Recovery Auditors, the requirement of a submitted claim and regulatory guidelines is essential for the review process. Recovery auditors utilize this information to determine if the claim is compliant with Medicare regulations and whether it should be paid according to established criteria.

The submitted claim details the services rendered and the corresponding codes, while the regulatory guidelines outline the specific requirements and rules that dictate proper billing practices. This combination allows auditors to assess the validity of the claim without necessarily needing additional records or documentation from the provider at this stage.

In automated reviews, the focus is on analyzing patterns and adherence to set rules, making it redundant to require medical records or detailed supporting documentation in this initial phase. Thus, having the claim and the applicable regulatory guidelines meets the needs of the automated review process effectively.