CMS Medicare Program Integrity Manual Updates ADR Timeframes for Submission/Results of Insufficient/No Response (6/20)

By CMS - June 20, 2020

SUBJECT: Publication (Pub.) 100-08 Chapter 3 Updates to Section (Timeframes for Submission) and Section (No Response or Insufficient Response to Additional Documentation Requests (ADRs))

I. SUMMARY OF CHANGES: The purpose of this Change Request (CR) is to clarify our authority to request and require documentation, upon request, to determine the appropriateness of claims for payment.

EFFECTIVE DATE: July 27, 2020 *Unless otherwise specified, the effective date is the date of service.



A. Background: In certain circumstances, the MACs, Comprehensive Error Rate Testing (CERT) Contractor, Supplemental Medical Review Contractor (SMRC), Recovery Audit Contractor (RAC), Unified Program Integrity Contractors and other contractors may not be able to make a determination on a prepayment or post-payment claim they have chosen for review based upon the information on the claim, its attachments, or the billing history found in claims processing system (if applicable) or the Common Working File (CWF). In those instances, contractors may require providers or suppliers to furnish medical and related supporting documentation in order to determine the amounts due for payment. CMS and its contractors require that sufficient documentation and information be furnished to support that selected claims meet applicable coverage, coding, and billing requirements for payment

During the medical review process, Medicare contractors may reach out to the provider or supplier and request documentation to support payment of the selected claims. Such documentation is reviewed to determine the appropriateness of a claim for payment based on its compliance with our coverage, coding, and billing requirements. Medicare contractors request documentation be provided in specified timeframes once a request for additional documentation is sent to the provider or supplier. In cases where no supporting documentation is received to conduct a medical review, the claim shall be denied. This change request clarifies our authority for to request and require documentation, upon request, to determine the appropriateness of claims for payment.