Medforce Blog

Did you know? Auto-denial of CMS Claims

June 25, 2015

Category: General


Have you ever seen a claim denied due to lack response or missing documentation, even though it was complete and received by the Review Contractor before the deadline? It could be due to a frustrating flaw in the Medicare Program Integrity Manual (PIM) guidelines.

Previously, the deadline for submission was 30 days, with a 15 day grace period. That gave you a 45 day window to submit the necessary documentation. Now, the deadline has been fully extended to that 45 day period, but no grace period has been added. This means that if the RC has received your documentation, but has not yet reviewed it, it will be automatically denied by the system. This is true whether you use fax, mail or esMD. The closer your submission is received to the deadline, the more likely it is that it will be auto-denied.

There is no denial code for auto-denial due to this deadline/grace period issue. The denial you receive will be the same as you would should you actually be missing documentation or had actually missed the deadline.

What next?
After a claim is auto-denied, it remains in the queue of the Review Contractor. Once they are able to review it, they will reopen the claim and either approve/deny based on actual facts – not on a false technicality. However, there is no stated timeline for when an auto-denied claim will be reviewed and given a fair ruling, and there is no notification when something has been reopened.

What can you do?
If you get a denial, but it is clear to you that you’ve followed all of the regulations and have the necessary documentation you have two choices. Unfortunately, neither is very attractive and both require you to do additional work.

Prepare and submit your appeal as you normally would for an unjustly denied claim.
Wait and follow up in a few weeks to see if the case has been reopened. Due to no designated timeline for the review, you may have to follow up multiple times until you get a straight answer.




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