Description
This claim is being denied. The provider failed to respond timely to the request for additional medical documentation. The next level review is done by the redetermination area. Requests for the redetermination department must be received within 120 days of the date of the denial.

Resolution
Medical records were not received by reviewing entity that requested Additional Documentation Request (ADR) within 45 days. If ADR was not received by entity, a Redetermination request should be submitted. In some cases, these will be handled as a reopening rather than a redetermination. Redetermination should include:

  • All applicable supporting medical documentation
  • Corrected UB-04 form

In some cases timing can be an issue. For example, if you respond to the Recovery Auditor on day 45 and they do not inform the MAC that they have received documents until day 46, claim may have denied 56900 incorrectly. If you have received a results letter from entity and claim is denied, contact Provider Contact Center (PCC).

Providers with Direct Data Entry (DDE) access should check ADR locations frequently. (SB6001) Providers who receive hard copy ADR requests should work within their facility to ensure that letters are reviewed and responded to timely. To avoid 56900 denials, providers are reminded to verify and respond expediently to entity that is requesting ADR.

Resource: CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, chapter 34 (PDF, 97 KB).

Contact Palmetto GBA JJ Part A Medicare

Provider Contact Center: 877-567-7271

Email JJ Part A

Contact a specific JJ Part A department


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