Documentation should inculde with appeal request

Documentation to include with your Appeal Request

Redetermination requests must include all pertinent medical documentation pertaining to the services in question.  The medical record documentation must include the patient’s name and must be complete and legible.  If you are making changes to the claim, include a copy of a revised UB-04 claim form.  In addition, if an Advance Beneficiary Notification (ABN) or other beneficiary notice was issued, include a copy of this document.

Remember that medical record documentation must be legible.  Each page of the record should identify the patient and the date.  A hand written or electronic signature and credentials should follow each record entry (stamp signatures are not acceptable).  The record should be of good copy quality for review purposes.

Effective August 1, 2008, Highmark Medicare Services will not routinely request additional inpatient documentation from providers who failed to submit all the necessary medical records.  The redetermination will be performed based on the medical record documentation that you submitted with your initial claim and appeal request.  Providers, physicians and other suppliers are responsible for providing all the information the contractor requires to adjudicate the claim(s) at issue.

If the service being appealed was denied due to a Local Coverage Determination (LCD), you should review the LCD policy for the documentation requirements that are necessary to support the service.  The LCDs are available on the Highmark Medicare Services internet site.

If the service being appealed was denied due to a National Coverage Determination (NCD), you should review the NCD policy for the documentation requirements that are necessary to support the service.  The NCDs are available on CMS’ website.

The following list may be used as a guideline (not all-inclusive list) when submitting documentation with your redetermination request.

OUTPATIENT RECORDS
Issue
Documentation
Cosmetic Surgery Surgical report, pathology report, history and physical , physician's progress notes
Dental Services Dental surgical report, pathology report, history and physical , physician's progress notes, physician orders and laboratory reports
Diagnostic Tests:  Radiology Physician orders, history and physical, test results, e.g., x-ray reports
Drugs (J codes) Physician orders, history and physical, medication record, nurses notes
Laboratory Services Physician orders, laboratory report(s), pathology report
Physical, Occupational, and  Speech therapy Physician orders, therapy evaluation and progress notes; physician certification/recertification
INPATIENT RECORDS
SKILLED NURSING FACILITY INPATIENT RECORDS
Issue
Documentation
Inpatient Hospital Complete Hospital Records including emergency room reports, admission history and physical, physician's orders and progress notes, consultation reports, nurses' notes, medication record, laboratory  and pathology reports, X-ray reports, operating room and anesthesia report, discharge summary, Advance Notice of Non-Coverage (signed by the beneficiary), denial notification issued by the provider, billing form
Inpatient Rehab Facility Complete Hospital Records including history and physical, physician's orders and progress notes, consultation reports, nurses' notes, medication record, laboratory reports, X-ray reports, therapy evaluation and progress notes, physician certification/recertification, Advance Notice of Non-Coverage(signed by the beneficiary), billing form
SNF Inpatient Hospital discharge summary, physician certification, progress notes, and orders, nurses notes, medication records, therapy records, if applicable, copy of the MDS, signed Advance notice of non-coverage and denial notification issued by the provider, if applicable

An appeal request for a claim that was denied by Medical Review (MR) for lack of documentation or for insufficient documentation must be submitted with all the medical record documentation that was requested in the additional documentation request (ADR).  The ADRs that you receive requesting additional supporting documentation are very specific regarding the type of information that is required.  Thoroughly review the ADR to be sure that all items requested in the ADR have been submitted with your appeal.

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