Monday, July 12, 2010

Denial reason as no documentation

Reasons for No Documentation Errors

No documentation issues are defined in the following six categories:

1. Beneficiary Issue - This category included situations in which:
The provider indicated that no such patient exists, or
The provider indicated that although this patient exists, no such service was provided to the patient.

2. Wrong Date of Service (DOS) - For this category, the provider indicated that they did not have a medical record for the date of service in the CERT request, but they do have a medical record for the same service just a few days before or after the service in question. The claim in question may be a duplicate claim.

3. Medical Record Issue - This category includes instances where the provider responded to a CERT documentation request but did not provide a medical record to support payment of a claim. This category includes the following situations:
The provider indicated that another department within the provider organization is responsible for fulfilling documentation requests,
The provider indicated they have the medical record but refused to provide it without payment for copying/mailing charges,
The provider indicated that it is a HIPAA violation to supply the record,
The provider submitted a statement that the record was destroyed as a result of extenuating circumstances (e.g., fire, flood, explosion),
The provider indicated in writing that they did not provide a service to the beneficiary on the date indicated on the claim, and
The provider indicated they have the medical record but refuse to provide it for some
other reason.

4. Billing Provider Issue - This category contains the following reasons for no documentation:
The provider number has been deactivated,
The provider has gone out of business, or
The provider commented, but failed to produce a record.

5. Third Party Record - This category contains situations in which the provider indicated that a different provider, a third party, has the relevant medical record.

6. Did Not Respond - No response to any CERT documentation request.

CMS attributed no documentation to multiple factors, including the providers’ lack of familiarity with the CERT Review Contractor, concerns about compliance with the Health Insurance Portability and Accountability Act (HIPAA), and cases where documentation did not exist. In some instances, all of the documentation may be located at a third party. If providers fail to contact the third party or the third party fails to submit the documentation, CMS counted the claim as a no documentation error.

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