No Response or Insufficient Response to ADRs

3.2.3.8 - No Response or Insufficient Response to ADRs (Rev.: 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) This section applies to MACs, RACs, CERT, SMRC, and UPICs, as indicated. A. ADRs The reviewer authority to request that documentation be submitted, to support claims payment, is outlined in Section 3.2.3.2 of this chapter. If information is requested from both the billing provider or supplier and/or a third party and no response is received within the expected timeframes (or within a reasonable time following an extension), the MACs, RACs, SMRC, and UPICs shall deny the claim, in full or in part, as not reasonable and necessary. Contractors shall use: • Claim Adjustment Group Code CO - Contractual Obligation; • Claim Adjustment Reason Code (CARC) 50 - these are non-covered services because this is not deemed a “medical necessity” by the payer; and • Remittance Advice Remark Code (RARC) M127 - Missing patient medical record for this service. MACs shall count these denials as automated review or non-medical record review depending whether the denial is automated or requires manual intervention. For claims that had a PWK modifier, and the unsolicited documentation was reviewed, the review shall be counted as medical record review. B. No Response During prepayment review, if no response is received within the expected timeframes, the MACs and UPICs shall deny the claim in accordance with 42 CFR §§ 405.903 and 405.930. During post-payment review, if no response is received within the expected timeframes (or extension), the MACs, RACs, UPICs and SMRC shall deny the claim as not reasonable and necessary. These contractors shall cite sections 1815(a), 1833(e), and 1862(a)(1)(A) of the Act, as well as 42 CFR §§405.929 and 405.930, when referring to the authority for requiring submission of documentation and denying claims for no response within the expected timeframes. The MACs shall count these denials as non- medical record reviews. C. Insufficient Response If the MAC, CERT, RAC, SMRC, or UPIC requests additional documentation to verify compliance with a benefit category requirement, and the submitted documentation lacks evidence that the benefit category requirements were met, the reviewer shall issue a benefit category denial. If the submitted documentation includes defective information (the documentation does not support the physician’s certification), the reviewer shall deny the claim as not meeting the reasonable and necessary criteria.