Postpayment Service-Specific Probe Results for Keytruda (Pembrolizumab) for April through June 2021

Published 07/26/2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code J9271 — Keytruda (Pembrolizumab). This edit was set in Alabama, Georgia and Tennessee. The results for the probe review, claims processed April through June, 2021, are presented here.

Cumulative Results 
A total of 113 claims were reviewed, with six of the claims completely or partially denied, resulting in an overall claim denial rate of 5.31 percent. The total dollars reviewed was $1,226,369.96, of which $49,616.31 was denied, resulting in a charge denial rate of 4.05 percent. Overall, there was a total of 18 auto-denied claims in the region.

Alabama Results
A total of 58 claims were reviewed, with three of the claims either completely or partially denied. This resulted in a claim denial rate of 5.17 percent. The total dollars reviewed was $601,954.43, of which $23,892.61 was denied, resulting in a charge denial rate of 3.97 percent. 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

100%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

3

Georgia Results
A total of 19 claims were reviewed, with none of the claims denied. This resulted in a claim denial rate of 0.0 percent. The total dollars reviewed was $207,460.91 of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent. 

Tennessee Results
A total of 36 claims were reviewed, with three of the claims either completely or partially denied. This resulted in a claim denial rate of 8.33 percent. The total dollars reviewed was $416,954.62, of which $25,723.70 was denied, resulting in a charge denial rate of 6.17 percent.

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

100%

5DMDP/5HMDP

Dependent Services/Items Denied Because Qualifying Services Denied Medically

3

Denial Reason and Prevention Recommendations

5DMDP/5HMDP — Dependent Services Denied (Qualifying Service Denied Medically)

Reason for Denial
The dependent services will not be covered if the qualifying service has been denied. For example, the service was denied as documentation did not support medical necessity; therefore, all other charges associated with the service under review cannot be allowed and will be denied as dependent to the medical denial of the qualifying service.

How to Avoid This Denial

  • Ensure the documentation provided supports the services were reasonable and medically necessary for the treatment of the beneficiary
  • Ensure all records are properly and legibly signed
  • Ensure documentation supports the service(s) was rendered

More Information

56900 — Auto Deny — Requested Records Not Submitted Timely 

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original Additional Development Request (ADR) to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the Additional Development Request (ADR) date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the Additional Development Request (ADR) is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the Additional Development Request (ADR). Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review Department. Fax and electronic data submissions are also accepted as indicated on the Additional Development Request (ADR).
  • Gather all of the information needed for the claim and submit it all at one time
  • Attach a copy of the Additional Development Request (ADR) request to each individual claim
  • If responding to multiple Additional Development Requests (ADRs), separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips. 
  • Do not mail packages C.O.D.; we cannot accept them

More Information

The Next Steps
The service-specific postpayment medical review edits for HCPCS Code J9271 — Keytruda (Pembrolizumab) in Alabama, Georgia and Tennessee will be continued based on moderate charge denial rates and/or medium to high impact severity errors. If significant billing aberrancies are identified; provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to Redetermination: 1st Level Appeal form.Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.