Medicare Compliance & Reimbursement

If you run behind on submitting your documentation for a claim under medical review, you may get a reprieve — depending on who your MAC is.

Medicare regulations require that “when the Medicare Administrative Contractor (MAC) requests documentation for prepayment or postpayment review, the provider must submit the documentation within 45 calendar days, or the claim shall be denied,” HHH MAC Palmetto GBA says on its website.

However: “If the MAC receives the requested information after a denial has been issued for non-receipt of requested records, the MAC has the discretion to reopen the claim,” Palmetto acknowledges.

“Palmetto GBA’s Medical Review department will reopen claims denied for non-receipt of requested medical records and will make a medical review determination on the lines previously denied if the requested documentation is received within 120 days of the claim’s Remittance Advice date of denial for non-receipt.”