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Printed Date: 9/22/2015
We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed in a timely manner. The following information affects Alabama, Georgia and Tennessee Part A providers.
# Claims Denied
Denial Reasons and Prevention Recommendations
56900 — Auto Denial — Requested Records Not Submitted
The services billed were not covered because the claim was not submitted, or not submitted on time in response to an Additional Documentation Request (ADR). When an ADR is generated, the provider has 45 days from the date the ADR is 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:
For more information refer to the articles on the Palmetto GBA website concerning the Medical Review Targeted Probe and Educate (TPE) Process.
5D700 - No Valid Plan of Treatment Present
The service(s) billed (was/were) not covered because a valid treatment plan established and approved by a physician was not included in the medical records submitted for review as required by Medicare.
In order to avoid unnecessary denials for this reason, when responding to an Additional Documentation Request (ADR), the provider should ensure that the appropriate treatment plan is included and that it is signed by the physician and the mental health professionals contributing to it.
The treatment plan should be developed within the first three days of admission. The focus should be individualized to the patient’s specific strengths and problems as identified in the physician’s psychiatric evaluation, and the psychosocial and nursing assessments. It should contain a substantiated diagnosis; both short-term and long-range measurable, functional, time-framed goals directed at the individual problems identified as the cause for the patient’s admission; a list of any specific treatment modalities to be utilized in the active treatment of the patient; and a listing of the responsibilities of each member of the treatment team as he/she relates to the plan.
Treatment plan updates should show the treatment plan to be reflective of active treatment as indicated by documentation of changes in the type, amount, frequency and duration of the treatment services rendered as the patient moves toward expected outcomes. Treatment plan updates should be documented at least weekly, as the physician and treatment team assess the patient’s current clinical status and make necessary changes. Lack of progress and its relationship to active treatment and reasonable expectation of improvement should also be noted.
For more information, refer to:
5J504 – Need For Services Not Medically and Reasonable Necessary
The claim has been fully or partially denied as the documentation submitted for review did not support the medical necessity of the services provided.
Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:
55503 — Line Denied Because Medical Necessity Was Not Supported as Outlined in Palmetto GBA's Local Coverage Determination (LCD)
The service(s) billed (was/were) not covered because medical necessity was not supported as outlined in Palmetto GBA's Local Coverage Determination (LCD).
In order to avoid denials for this, please refer to Palmetto GBA's Local Coverage Determination (LCD). Psychiatric Inpatient Hospitalization Local Coverage Determinations (LCD – L34570) is on the Palmetto GBA website.
5D800 – Inpatient Psychiatric Services Not Medically Necessary
Documentation submitted for review did not support the medical necessity for inpatient psychiatric services.
For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:
5J502 – Info Submitted Does Not Support Dates Billed
The documentation submitted was for the incorrect dates billed or for the incorrect beneficiary.
5D161 — No Physician’s Orders
This claim was fully or partially denied because there were no physician’s orders submitted for review for all or some of the services billed.
For more information, refer to:
5D650 – No Valid Certification/Recertification Present
The service(s) billed (was/were) not covered because a valid certification/recertification signed by the physician was not included in the medical records submitted for review as required by Medicare.
For more information refer to:
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Last Updated: 11/16/2018