© 2020 Palmetto GBA, LLC
We frequently update our articles to reflect the latest changes and updates to Medicare, and strongly recommend you visit this article at link below to confirm you have the latest version.
Printed Date: 9/22/2015
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.
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:
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).
We value your opinion and want to provide the highest-quality and most relevant Medicare knowledge possible. Please let us know if this article was helpful.
It didn't answer my question
This article was helpful
We’re glad we could help you today and appreciate your feedback. When you rate our articles as most helpful, we know that we are on the right track for providing you with important news and information.
We're sorry this article didn't help you today. We'll use your feedback to review this article to try to revise or expand it. Contact us with more feedback or a question on this topic.
Last Updated: 12/16/2019