Medical Records to Support an Appeal
Do NOT submit an original UB-92 with your appeal
request.
The provider is responsible for providing all of the information needed
to support payment of its claim. If the provider has requested the
appeal, additional information will not be requested. The documentation submitted
should support ALL aspects of coverage. This means that if
a service was denied because there was no order, the order AND the service note(s)
should be submitted so it can be verified that the service was rendered as ordered,
correctly billed and medically necessary. Failure to submit records can result
in maintaining the denial for insufficient information to support payment.
Requests from the Beneficiary or Individual Other than the Provider
When a party other than the provider submits an appeal request, UGS requests
medical records from the provider. This medical record request is sent to the
provider's business office. These records must be returned to UGS within
calendar 14 days. If the records are not returned within this time
frame, the provider will be held liable because there is no documentation to
support the services were reasonable and necessary.
Outpatient Therapy Providers
42CFR424.24 and 410.60-410.62 require that outpatient therapy services be
ordered and certified by a physician. This serves as a reminder that, when submitting
an appeal request for therapy services, all documentation, including
the certification/re-certification(s), should be submitted with all
other documentary evidence to support the assertion that the care is covered,
regardless of the reason for which it was denied.
Outpatient Laboratory Tests
Providers are responsible for submitting all documentation to support the
appeal request. In the case of laboratory tests, submitting only an
acceptable diagnosis code is not enough. The provider must submit physician's
records to support that the test was medically necessary and not just a routine
test to check a stable, pre-existing condition. This is especially true for
chronic conditions. There must be documentation of an acute condition, or of
a change in an existing condition, to warrant the test.
All appeal requests for denied laboratory tests should include a complete list
of the patient's diagnoses and all results for the denied laboratory test(s)
that are being appealed. These requests must also include at least one of the
following, dated prior to the services in question, to support
that the beneficiary's condition meets coverage requirements:
- The physician's order and office/clinic notes
- Office/clinic notes
- A recent history and physical
Physician's orders, office/clinic notes and/or history and physical reports
dated after the services in question will not support the need
for the denied services.
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