Q1. A claim was denied because the submitted documentation did not support the medical necessity of the diagnostic service. What documentation is required to support these services?
A1. Providers should review Additional Documentation Request (ADR) letters in their entirety for identification of the required documentation necessary for review. Generally, most diagnostic services would need documentation from the ordering provider that includes orders/intent to order, and progress notes supporting the medical necessity of the service under review, and results of the service under review. Additionally, reviewing CMS coverage criteria through National Coverage Determination (NCD) and Local Coverage Determination (LCD) guidelines, if applicable, can provide indications for medical necessity and clarify coverage criteria.

For more information, visit the following website pages:

• Documentation Requirements
• Laboratory Documentation Requirements
• Radiology Documentation Requirements
• CMS Website - Local Coverage Determination
• Noridian Medicare Website - Local Coverage Determination
• Medicare Coverage Database

Q2. Why did my claim deny 56900 and what do I need to do for the claim to be reviewed?
A2. This code indicates that the requested Additional Documentation Request (ADR) was not received within 45 days of notification. The Medical Review (MR) process allows providers to request an MR claim reopening when the denial is identified as a technical denial specifically related to missing and/or insufficient documentation. If the provider does respond close to the 45-day timeframe, it is possible that the claim may deny 56900 as the system has not yet updated receipt of the documentation. Providers may also request a Redetermination or Reopening after the 45-day timeframe by submitting a Redetermination/Reopening Form.

For more information, visit the following Noridian Medicare website pages:

• Reason Code 56900
• Medical Review Reopening
• Redetermination/Reopening Form

Q3. When is it acceptable to rebill a claim?
A3. Claims should only be resubmitted if the claim is denied for a processable error such as when a claim rejects for missing, invalid, or incomplete information. If the provider has made an error when submitting the claim or disagrees with the claim decision, a provider should follow the self-service reopening or appeals process to make corrections to the claim or appeal the decision. If a claim is rebilled as a duplicate, it will be denied. Providers who are found to be billing duplicate claims during the review will be educated on the error. If providers continue to submit duplicate claims despite education, program integrity action may be taken. Refer to IOM 100-04 Medicare Claims Processing Manual, Chapter 1, Section 120 on General Billing Requirements.