Medical Review Intent to Reopen Process for Non-Receipt of Medical Record Denials

Published 03/13/2020

When the Medicare Administrative Contractor (MAC) requests documentation for prepayment or postpayment review in order to make a determination about coverage and payment under Section 1862(a) (1) (A) of the Act, the provider must submit the documentation within 45 calendar days, or the claim shall be denied.

If the MAC receives the requested information after a denial has been issued for non-receipt of requested records, the MAC has the discretion to reopen the claim. Palmetto GBA's Medical Review department will reopen claims denied for non-receipt of requested medical records and will make a medical review determination on the lines previously denied if the requested documentation is received within 120 days of the claim's Remittance Advice date of denial for non-receipt.