Postpayment Service-Specific Probe Results for Drugs and Biological Services: Denosumab (Prolia) for April through June 2021


Postpayment Service-Specific Probe Results for Drugs and Biological Services — Denosumab (Prolia®) — in North Carolina, South Carolina, Virginia and West Virginia for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on: HCPCS Code J0897 — Denosumab (Prolia®). This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed April through June, 2021, are presented here.

Cumulative Results 
A total of 289 claims were reviewed with 133 of the claims either completely or partially denied, resulting in an overall claim denial rate of 46.02 percent. The total dollars reviewed was $327,695.60, of which $150,785.72 was denied, resulting in a charge denial rate of 46.01 percent. Overall, there were no auto-denied claims in the region. 

North Carolina Results
A total of 78 claims were reviewed, with 36 of the claims either completely or partially denied. This resulted in a claim denial rate of 46.15 percent. The total dollars reviewed was $88,480.52, of which $40,926.86 was denied, resulting in a charge denial rate of 46.26 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

80.56%

NOTMN

Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

29

19.44%

NODOC

Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(A) (1) (A) of the Act for the Service Billed and this Service Has Been Denied

7

South Carolina Results
A total of 40 claims were reviewed, with 23 of the claims either completely or partially denied. This resulted in a claim denial rate of 57.50 percent. The total dollars reviewed was $45,337.20, of which $26,052.90 was denied, resulting in a charge denial rate of 57.46 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

65.22%

NOTMN

Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

15

17.39%

DNSRP

Documentation Not Signed by the Rendering Provider

4

13.04%

NODOC

Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(A) (1) (A) of the Act for the Service Billed and this Service Has Been Denied

3

4.35%

NOSIG

Documentation Lacks the Necessary Provider's Signature

1

Virginia Results
A total of 151 claims were reviewed, with 66 of the claims either completely or partially denied. This resulted in a claim denial rate of 43.71 percent. The total dollars reviewed was $171,242.46, of which $74,660.88 was denied, resulting in a charge denial rate of 46.30 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

87.88%

NOTMN

Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

58

9.09%

NODOC

Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(A) (1) (A) of the Act for the Service Billed and this Service Has Been Denied

6

1.52%

BILER

Claim Billed in Error Per Provider

1

1.52%

DNSRP

Documentation Not Signed by the Rendering Provider

1

West Virginia Results
A total of 20 claims were reviewed, with eight of the claims either completely or partially denied.This resulted in a claim denial rate of 40.0 percent. The total dollars reviewed was $22,635.42, of which $9,145.08 was denied, resulting in a charge denial rate of 40.40 percent. The top denial were reasons identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

62.50%

NOTML

Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

5

37.50%

NOTMN

Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

3

Denial Reasons and Prevention Recommendations

NOTMN — Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

NODOC — Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(A) (1) (A) of the Act for the Service Billed and this Service Has Been Denied

  • Submit all documentation related to the services billed within 45 days of the date on the ADR letter
  • Review documentation prior to submission to ensure that the documentation is complete and that all dates of service requested are included
  • Include any additional information pertinent to the date of service requested to support the services billed. For example: original chart notes, diagnostic, radiological or laboratory results.
  • For claims denied with a M127 or N29 code listed on the remittance advice, be sure to submit all documentation for all dates of service on that claim with a reopen/redetermination request form by fax to JM Part B (803) 699–2427, JJ Part B (803) 870–0139, or RRB Appeals (803) 462–2218
     

NOTML — Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

DNSRP — Documentation Not Signed by the Rendering Provider

BILER — Claim Billed in Error Per Provider

  • Prior to billing claims, review the information to determine that the correct information is listed in the appropriate fields
  • For all claims previously billed and denied by medical review, do not resubmit the claims. If you disagree with the decision from medical review, you must submit the appropriate documentation with a completed redetermination request form to the appeals department. This information can be sent by fax to JM Part B Appeals (803) 699–2427, JJ Part B Appeals (803) 870–0139, or RRB Appeals (803) 462–2218.
  • If documentation indicates that both an NPP and a physician performed the service, and the claim is billed under the physician’s NPI, the billing physician must sign the record. Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantive portion of the E/M visit. (A substantive portion of the E/M visit includes at least one of the three key components: history, exam, or medical decision-making.)
  • If documentation occurs in a teaching environment, review the documentation to ensure that the billing provider has provided a teaching attestation and a signature
     

NOSIG — Documentation Lacks the Necessary Provider's Signature

The Next Steps
The service-specific targeted medical review edits for Drugs and Biological Services: HCPCS Code J0897 – Denosumab (Prolia®) in North Carolina, South Carolina, Virginia and West Virginia will be continued based on moderate charge denial rates and 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 the JM Redetermination: 1st Level Appeal form (PDF, 223 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.





Last Updated: 09/10/2021