“Requested records not submitted” was the cause of 44.5% of claim denials under medical review in the last three months of 2024, according to Palmetto GBA.
 
The Medicare Administrative Contractor for 16 states released its top reasons for denial March 17.
 
Palmetto offered these tips to avoid these denials:
  • Monitor your claim status on Direct Data Entry (DDE).
  • Aim to submit medical records within 30 days of the ADR date. The claim will auto deny on day 46.
  • Gather all information needed for the claim and submit it all at one time.
  • Submit medical records as soon as the ADR is received.
  • Attach a copy of the ADR request to each individual claim.
  • If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost.
  • Do not mail packages C.O.D.
  • Return the medical records to the address on the ADR.
“No plan of care or certification” was number two with 27.5% of denials and “Face-to-face encounter requirements not met” was in third with 12.5% of denials.
 
See the list with links to Palmetto’s guidance at https://www.palmettogba.com/palmetto/jmhhh.nsf/DIDC/SCHFC1C1OF~Claims.