How to avoiding denial and appeal of supporting documentation

To avoid appeal

 Comply with requests for supporting documentation. Failure to comply with the request will result in a denial.

    * The process whereby a contractor requests additional documentation after claim receipt is known as “development”. When a coverage or coding determination cannot be made based upon the information on the claim and its attachments (e.g., due to a medical review of the service/claim), contractors may solicit for more information from the provider by issuing an Additional Documentation Request (ADR). Highmark Medicare Services will specify in the development letter or ADR the piece(s) of documentation needed to make the coverage or coding determination.

    * For responses to development that are received within the 45-day timeframe, Highmark Medicare Services will complete the review and notify the provider and beneficiary, if indicated, of the claim determination within 60 days of receiving all the requested documentation. For record or documentation requests where no timely response was received, Highmark Medicare Services will indicate that the denial was made without reviewing the medical record because the requested records were not received or were not received timely.



 The supporting documentation must include the rendering physician’s signature. Failure to provide a valid signature will result in a denial.

    * Medicare contractors require a legible identifier for services provided or ordered.
    * The only acceptable method of documenting the provider signature is by written or an electronic signature.
    * Stamp signatures are not acceptable to sign an order or other medical record documentation for medical review purposes.

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