Ob-Gyn Coding Alert

Question: We have a few claims under medical review, and when we went to send the backup documentation, we realized we had missed the deadline by two days. What should we do?

Ohio Subscriber

Answer: 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 post-payment review, the provider must submit the documentation within 45 calendar days, or the claim shall be denied,” 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.”

Therefore, if you discover that you’re behind on record submissions, contact your MAC immediately and see if there is any recourse for late records. But keep in mind that this is how Medicare would handle the late submission. Commercial payers may be less willing to do so. When you know your claim in under review, you should create a work-flow sheet with due dates so that this does not happen in the future.