February 3, 2023
Reminders About Third-Party Additional Documentation Requests
Per the CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3:
Section 3.2.3.3 – Third-party Additional Documentation Request
- Unless otherwise specified, requested information shall be sent to the billing provider/supplier.
- Because the provider selected for review is the one whose payment is at risk, they are the provider who is ultimately responsible for submitting, within the established timelines, the documentation requested.
- Per Medicare guidelines the CERT (Comprehensive Error Rate Testing) contractor can contact the referring provider as submitted/identified by National Provider Identifier/Unique Physician Identification Number on the claim when such information is not sent in by the billing supplier/provider.
Section 3.2.3.7 – Special Provisions for Lab Additional Documentation Requests
- When an ADR (Additional Documentation Request) for a lab service is requested, the following documentation should be submitted (please note this is NOT an all-inclusive list):
- The order for the service billed (including sufficient information to allow the reviewer to identify and contact the ordering provider)
- Verification of accurate processing of the order and submission of the claim
- Diagnostic or other medical information supplied to the lab by the ordering provider, including any diagnosis codes or narratives.
- The contractor shall review information from the lab and find it insufficient before the ordering provider is contacted. The contractor shall send an ADR to the ordering provider that shall include sufficient information to identify the claim in question.
- If the documentation received does not demonstrate that the service was reasonable and necessary and/or if a benefit category, statutory exclusion, or coding issue is in question the contractor shall deny the claim.
- The contractor shall deny the claim if a benefit category, statutory exclusion, or coding issue is in question, or send an ADR to the ordering provider to determine medical necessity.
- If information is requested from both the billing provider or supplier and/or a third party and no response is received within the expected timeframes (or within a reasonable time following an extension), the claim shall be denied, in full or in part, as not reasonable and necessary.