1-1

RESERVED

2-1

MEDICARE DOCUMENTS FILE. Health Care Financing Administration (HCFA) 1500 Billing Forms, Uniform Billing (UB) 82 Forms, Fiscal Intermediary (FI), Notice of Professional Review Organization (PRO) Adjustments, Provider International Classification of Diseases (ICD) 9/Diagnosis Related Group (DRG) Surveys, remittance advice, Notice of Medicare Claim Determinations, Medicare Information Requests, adjustment explanations, suspended claims awaiting replies, Medicare cost reports, monthly/year-to-date reports, Medicare outpatient billing reports, Medicare patient lists and Consolidated Alphabetical State Files (CASF).

Cut off upon close of case.  Transfer to the FRC when 3 years old.  Destroy when 6 years, 3 months old.  AUTH:  N1-513-92-5

2-2

MEDICAID DOCUMENTS FILE.  Statements of Remittance, Medicaid denial letters, claims correction letters, proposed regulations and correspondence from State Medicaid Human Services Department, eligibility/criteria manual updates, monthly/year-to-date billing/collection reports, patient registration reports, Medicaid billing reports, and Medicaid patient lists.

Cut off upon close of case.  Transfer to the FRC when 3 years old.  Destroy when 6 years, 3 months old.  AUTH:  N1-513-92-5

2-3

PRIVATE INSURANCE (PI) DOCUMENTS FILE. Reports of PI utilization batch verifications, facility orders, Area Office database posting logs, PI transmittal logs, PI inpatient/outpatient worksheets, monthly/year-to-date bill/collection reports, schedule of collections, field receipts, Explanation of Benefits (EOBs), HCFA 1500 Billing Forms, UB 82 Billing Forms, and Blue Cross/Blue Shield Dental Claim Forms.

Cut off upon close of case.  Transfer to the FRC when 3 years old.  Destroy when 6 years, 3 months old.  AUTH:  N1-513-92-5

2-4

PEER REVIEW ORGANIZATION (PRO) DOCUMENTS FILE. Manual updates for scope of work/criteria, DRG changes, denial letters, Notifications of Review Determinations, patient review abstracts, and PRO-GRAM newsletters.

a. Denied cases and cases submitted for reconsideration.

b. Other documents.

Cut off on final decision. Destroy when 7 years old.
AUTH: N1-513-92-5

Cut off annually. Transfer to the FRC when 3 year old. Destroy when 5 years old.
AUTH: N1-513-92-5

2-5

OUTPATIENT FEE BASIS FILES.  Tabulating cards, listings, and code sheets used to acquire and control fee basis medical services and to accumulate internal management data.

See Schedule V, Item 2-20.
AUTH: N1-513-92-5

3-1

CONTRACT HEALTH SERVICES CLAIMS ADJUDICATION FILE.  Case files include appeals of denials for payment for Contract Health Services (CHS) and management determinations involving, if appropriate, medical records, eligibility for alternate resources, Federal regulations, IHS policies, existing case law and precedents, legal and/or medical opinions, documentation of events involved in each case, and other related documents.

Cut off on close of case.  Destroy when 6 years, 3 months old.  AUTH:  N1-513-92-5

3-2

CATASTROPHIC HEALTH EMERGENCY FUND. These files document the IHS-wide guidance of the management, monitoring and general oversight governing the usage of the Catastrophic Health Emergency Funds for high cost cases affecting IHS Areas and tribally operated facilities.  Patient case files include those determined to be a "catastrophic illness" based on conditions that are costly by virtue of the intensity and/or duration of their treatment.

a. Patient case files.

b. Other documents.

Return to Medical Records Section for disposition in accordance with Schedule 3, Item 3-1.  AUTH:  N1-513-92-5

Cut off at the end of the fiscal year.  Destroy when 5 years old.  AUTH:  N1-513-92-5

3-3

FISCAL INTERMEDIARY FILE. These files document the IHS-wide guidance of the management, monitoring and general oversight governing the usage of the fiscal intermediary contract awarded to operate, on a nationwide basis, a claims processing system for the IHS CHS Program.

Cut off at the end of fiscal year.  Destroy when 3 years old.  AUTH:  N1-513-92-5

3-4

MEDICAL CONTRACT FILE. Case files including copies of public health contracts and related evaluation reports concerned with medical, dental, x-ray, clinical laboratories, contracts with physicians, institutions, and other groups, and related documents.

Cut off on administrative closeout. Transfer to the FRC when 2 years old. Destroy when  6 years, 3 months old. AUTH: N1-513-92-5

4-1

RESERVED

5-1

RESERVED