Q1: Will successful appeals change whether I move to the next round of review (TPE or post‑pay)?
A1: Appeal outcomes are reviewed, but they do not automatically stop or reverse future review activity.

Before starting a subsequent round of review, Medicare Administrative Contractors (MACs) may consider appeal or reopening outcomes that affect the overall error rate. However:

• Each round of review is based on defined criteria and performance thresholds.
• Favorable appeal results do not guarantee that additional review will not occur.
• Providers will be notified in writing when a new round of review is initiated.

If you have questions about how appeal activity may impact a specific review, we recommend contacting the Provider Contact Center for general guidance (claim‑specific inquiries cannot be addressed through education forums).

Refer to Noridian Provider Contact Center

Q2: What documentation is required to support medical necessity for a service or CPT® code?
A2: Documentation must clearly support medical necessity based on Medicare coverage requirements and the patient's individual clinical circumstances.

What to include in your records:

• A clear reason why the service was needed for the patient
• Relevant history, physical exam findings, and/or diagnostic results
• How the service relates to the patient's condition or symptoms
• Documentation that supports any Local Coverage Determination (LCD) or National Coverage Determination (NCD), when applicable

Medical reviewers rely only on what is documented in the medical record. Statements such as "same as above" or referencing another date of service are not sufficient. Services must be supported by documentation for each date of service.

For policy‑level questions or education, providers may submit general questions through Ask‑the‑Contractor Meetings (ACMs) or Provider Outreach & Education (POE).

Refer to Noridian Provider Outreach and Education

Q3: Why was my claim denied even though documentation was submitted?
A3: A denial may occur if records were not received timely, were incomplete, or did not meet medical necessity per Medicare requirements.

Common reasons include:

• Records were not received by the due date listed on the Additional Documentation Request (ADR)
• Submitted records did not include all required elements
• Documentation did not support medical necessity under Medicare guidelines
• Records submitted did not correspond to the specific claim or date of service requested

What providers can do:

• Carefully review ADR letters for due dates and record requirements
• Submit complete records for the exact claim and date requested
• Ensure documentation clearly supports why the service was reasonable and necessary

Specific claim determinations are outlined on your Medicare Remittance Advice and/or viewed in the Noridian Medicare Portal. If not agreeable with the determination, follow the Noridian appeal process.

Refer to Noridian Medicare Portal and Noridian Appeals.