Caring for Medicare Patients is a Partnership
This revised MLN Product comprises Subregulatory Guidance for Medicare medical necessity coverage criteria and documentation guidelines for when providers partner to provide patient care. Its content is based on publically available content within the Social Security Act, Section 1862 at https://www.ssa.gov/OP_Home/ssact/title18/1862.htm, Section 1842 at https://www.ssa.gov/OP_Home/ssact/title18/1842.htm, and the HIPAA Privacy Rule at https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html. The Comprehensive Error Rate Testing (CERT) A/B MAC Outreach & Education Task Force members provided input, and CMS subject matter experts also reviewed/cleared this fact sheet. This fact sheet educates providers who partner to provide patient care about the information and documentation they need to share to support medical necessity, what may occur if the documentation is incomplete, and provides specifics on what items to document. Revisions to this product include:
• Updated the title for better clarity (page 1)
• Clarified that understanding coverage criteria and documentation guidelines helps ensure quality patient care (page 2)
• Added a note that other coverage and payment rules may apply (page 2)
• Added Supplemental Medical Review Contractor (SMRC) to the list of claims audit contractors (page 2)
• Added language to clarify that a patient may pay additional costs if documentation is incomplete (page 3)
• Added bullets to emphasize that all partnering providers must have necessary information and documentation (page 3)
• Deleted the list of CERT A/B MAC Task Force medical directors
The previous version of this product (previously titled “Caring for Medicare Patients is a Partnership”) is available to the public and currently posted on the CMS website at
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Caring-for-Medicare-Patients-is-a-Partnership.pdf.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: March 03, 2022
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.