Documentation Submission Responsibilities

When medical records are requested, the billing provider is responsible to obtain sufficient documentation to support the medical necessity of the service(s) billed. If the documentation is insufficient to support medical necessity, the claim may be denied.* National Government Services expects that the patient's medical records will reflect the need for the medical care provided.

The supporting documentation includes any third party documentation, such as the treating physician’s documentation, that may be available only through the physician’s office.

When submitting records for review to National Government Services or the CERT contractor, please ensure:

• Documentation is legible including the physician’s signature and no highlighting is used on medical records
• Records are for all services and dates of service on the claim
• The medical records submitted provide proof that the service(s) was ordered, rendered by the medical doctor (MD) or appropriate nonphysician provider, and  provide justification to support the medical necessity

For questions regarding documentation needed:

Contact National Government Services (See “Provider Contact Center" in "Contact Us”)

When submitting records for review to the CERT contractor, please complete the following steps:

• Photocopy (front and back) the requested record as identified in the CERT contractor request
• Submit the CERT bar code sheet with a copy of the medical records or a cover sheet with the CID#
• Submit electronically, fax or mail the medical records to the CERT contractor:
  • Preferred method of receiving records is electronically (currently esMD is available) or via fax at 804-261-8100
  • If unable to submit electronically or fax records (especially faxing large records), records may be submitted on a CD or hardcopy. Mail to:

CERT Documentation Center
CID #
1510 East Parham Rd.
Henrico, VA 23228

Option to Mail Medical Records on CD

Providers submitting documentation via CD should send the password to CERTmail@nciinc.com; use the CID number in the subject line of your email (no PHI). 

Note: There is no need for the provider to encrypt the password email. Following this procedure will ensure there is no delay in processing the documentation.

Note: Where physician signature is required - Signature key or attestation statement is needed if signature is not legible. This should include physician typed or printed name and signature. If orders are on an electronic ordering system—include protocol describing - physician enters the electronic system with unique ID and password.

* Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider.”

Suggested documentation to be obtained (not all inclusive and depends on the services billed) is as follows:

• Physician progress notes documenting visit billed or medical necessity of services ordered
• Physician orders (for inpatient hospital, observation, laboratory, diagnostic and therapeutic services)
• Treatment plans—initial and current (with physician signature)
• Nurses' notes
• Medication administration records
• Graphic reports
• Operative reports
• Pathology reports
• Consultation notes
• Referring physician report
• Laboratory reports
• Diagnostic test results (regardless of where they are performed)
• History and physical notes
• Hospice records
• Home health progress notes
• Certificate of Medical Necessity
• Skilled nursing facility records (including minimum data set [MDS] look back periods)
• Ambulance records
• Emergency room records
• Therapy progress notes and reports
• Treatment logs with documentation of total treatment time for timed modalities
• Initial evaluations and current reevaluations for ongoing therapeutic services with MD signature and diagnoses and conditions showing medical necessity
• Inpatient hospital admission evaluation and information to support medical necessity of inpatient stay.
  • In the case of inpatient admission for surgery, include documentation from prior to admission/surgery such as progress notes showing:
    • conservative treatment attempted (medications, therapy)
    • patient symptoms/conditions (necessitating surgery)
    • radiologic evidence (showing need for surgery)
• Inpatient Rehabilitation Assessment Instrument (IRF-PAI) for inpatient rehabilitation service(s)
• Chiropractic treatment plan notes/logs including the previous six months treatment documentation if for the same condition as sampled claim