Attention MD/DC Providers:

Highmark Medicare Services, routinely performs data analysis as required by CMS to verify that services are being billed to the Medicare program correctly.  Based on this analysis we frequently make the decision to review a sample number of medical records to assess for medical necessity of the services billed.  At this time we are notifying our providers that we will be reviewing a sample of approximately 60 claims for the High and Medium Rug Categories.  Claims will be pulled across all providers billing RH and RM Rugs. When you receive a request for additional information (ADR) please read the ADR letter carefully and submit the necessary documentation for review.

NOTE:  THE MOST FREQUENT REASON FOR DENIAL IS INSUFFICIENT DOCUMENTATION.  Please ensure all requested information is submitted.  We also encourage providers to refer to the CMS Manual 100-02 Medicare Benefit Policy Manual, Chapter 8- Coverage of Extended Care (SNF) Services Under Hospital Insurance and Manual 100-04 Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing. 

Compliance with sending all of the documentation will assist in timely adjudication of the claim.  This may eliminate the need for an appeal and can save the valuable resources of all parties with an interest in the claim.  Sufficient documentation for payment also results in a lower error rate, decreasing the likelihood of further review.