56900 - Auto Denial - Requested Records Not Submitted
The services billed were not covered because the claim was not submitted or not submitted timely in response to an Additional Documentation Request (ADR). When an ADR is generated, the provider has 45 days from the date the ADR was generated to respond with medical records. In accordance with CMS instructions, if the documentation needed to make a medical review determination is not received within 45 days from the date of the documentation request, Palmetto GBA will make a medical review determination based on the available medical documentation. If the claim is denied, payment will be denied or an overpayment will be collected.
To prevent this denial:
- Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
- Submit the medical records as soon as the 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 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. Gather all of the information needed for the claim and submit it all at one time.
- Attach a copy of the ADR request to each individual claim
- If responding to multiple 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 bound securely with one staple in the upper left corner or a rubber band 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
For more information, refer to the Targeted Probe and Educate Process article on the Palmetto GBA website.