Health Information Management

CMS changes timeframe for response to ADRs

HIM-HIPAA Insider, November 24, 2014

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CMS clarified changes to the Medicare Program Integrity Manual that alter the timeframe for responding to Additional Documentation Requests (ADR) and requirements for pre-payment review in MLN Matters® MM8583.

 
The MLN Matters guidance is based on information in Change Request 8583 and is relevant to providers submitting claims to Medicare Administrative Contractors (MAC). CMS review contractors may not be able to make a determination about a claim based on the claim itself, attachments, and patient’s billing history. In these circumstances, the review contractor must use an ADR to request additional information from a provider or supplier.
 
CMS requires MACs and Zone Program Integrity Contractors to produce pre-payment review ADRs allowing providers and suppliers 45 days to respond to an ADR. If the provider fails to respond, the carrier will deny the claim.

 



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