Q: Why can't the appeals department just get the medical records that were sent in to the Medical Review Department?  

A: The Centers for Medicare & Medicaid Services mandate that the appeals unit and the medical review unit remain separate entities and that the review is performed independently by each department.

The appeal gives the provider another opportunity to gather and submit all of the medical records, which includes the documentation previously sent to medical review and the missing documentation that caused the claim to be denied.

Q: Does the appeals department look at the entire medical record or just the item or service that was missing in Medical Review?