Reopenings of Denials Based on an Unanswered Additional

10.3 - Reopenings of Denials Based on an Unanswered Additional Documentation Request (ADR) (Rev. 1069, Issued: 09-29-06, Effective: 11-29-06, Implementation: 11-29-06) If a claim is suspended for medical review, an ADR may be issued to obtain information needed to make a determination. Providers, physicians, and suppliers are responsible for providing the information needed to adjudicate their claims. If no response is received to the ADR within the specified timeframes, the medical review department will likely deny the service as not reasonable and necessary based on a lack of documentation. If such a denial is appealed, the Medical Review department at the contractor shall perform a reopening instead of an appeal if all of the following conditions are met: 1) A provider failed to timely submit documentation requested through an ADR; 2) The claim was denied because the requested documentation was not received timely; 3) The requested documentation is received after the 45 day period with or without a request for redetermination or reopening; AND, 4) The request is filed within 120 days of the date of receipt of the initial determination. If all 4 criteria are not present, the request is for a redetermination and it is submitted within 120 days of the date of receipt of the initial determination, handle it as an appeal and do not ship the case back to MR. In this instance, the request must meet the criteria for a valid request for redetermination (see Pub. 100-04, Chapter 29, §310.1) in order for the appeals unit to accept the request. The CMS is handling these requests outside of the appeals process because CMS wants to encourage providers, physicians and suppliers to submit documentation when requested in order to prevent unnecessary appeals. Contractors should note that this requirement does not extend the time frame for filing an appeal. Therefore, only those appeal requests that are submitted within 120 days of the date of receipt of the initial determination and meet all of the criteria above should be shipped back to MR for a reopening. When the appeals unit ships cases back to the MR unit, MR must reopen those cases. If the request is submitted after 120 days, contractors may grant a regular reopening at their discretion or dismiss the request if no good cause explanation is provided for the late filing. If the ADR reopening results in an affirmation of the original denial or an adverse decision, the provider will retain their right to a redetermination. The date of the MR decision will be the date used to calculate the 120 days to request a redetermination.