Providers will have 45 calendar days, instead of the current 30 days, to respond to additional documentation requests (ADRs) during prepayment reviews from Medicare auditors, or their claim will be denied, according to a recent transmittal from the Centers for Medicare and Medicaid Services. The transmittal, R554PI (change request 8583), originally issued on Nov. 14, was revised on Nov. 18 to make corrections in the prepayment review section concerning ADRs. This transmittal applies to Medicare contractors such as Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), Recovery Auditors, Comprehensive Error Rate Testing contractors, and Supplemental Medical Review Contractors in different circumstances. In prepayment reviews, MACs and ZPICs should not extend the 45-day time frame for providers who need more time and “shall” deny the claim on day 46. Use of the term shall, according to the transmittal, means the requirement is mandatory. Documentation Requests Should Include the 45-Day Deadline In cases where a Medicare contractor does not receive sufficient information to adjudicate a claim based on the information it received with the claim or that may be available in the billing history or in the common working file, it will solicit additional information from the provider or supplier that […]
Providers will have 45 calendar days, instead of the current 30 days, to respond to additional documentation requests (ADRs) during prepayment reviews from Medicare auditors, or their claim will be denied, according to a recent transmittal from the Centers for Medicare and Medicaid Services.
The transmittal, R554PI (change request 8583), originally issued on Nov. 14, was revised on Nov. 18 to make corrections in the prepayment review section concerning ADRs.
This transmittal applies to Medicare contractors such as Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), Recovery Auditors, Comprehensive Error Rate Testing contractors, and Supplemental Medical Review Contractors in different circumstances. In prepayment reviews, MACs and ZPICs should not extend the 45-day time frame for providers who need more time and “shall” deny the claim on day 46. Use of the term shall, according to the transmittal, means the requirement is mandatory.
Documentation Requests Should Include the 45-Day Deadline
In cases where a Medicare contractor does not receive sufficient information to adjudicate a claim based on the information it received with the claim or that may be available in the billing history or in the common working file, it will solicit additional information from the provider or supplier that submitted the claim. The contractor is authorized to collect additional medical documentation to determine the correct amount due to the provider submitting the claim under Section 1833(e) of the Social Security Act. According to Chapter 3, Section 3.2.3.2 of Pub 100-08, Medicare Program Integrity Manual, the ADR must include the 45-day deadline.
It is important to note that the changes describe in this transmittal are applicable to prepayment reviews conducted by MACs and ZPICs only and do not include post-payment reviews. Post-payment reviews are not affected by this transmittal, so contractors have the discretion to allow an extension of the 45-day deadline completely at their own discretion in that case.
The effective date of this change is April 1, 2015, with an implementation date of April 15, 2015.
Takeaway: Providers will have a little longer to respond to prepayment review additional documentation requests from Medicare contractors.
