Help with Submitting Documentation to Novitas
Novitas Solutions’ Medical Review Department has noticed an increase in the improper submission of documentation in response to an Additional Documentation Request (ADR) and has provided the following information to help alleviate the problem.
Multiple occurrences have been identified of providers submitting redetermination forms in response to an ADR. Redetermination forms should never be used to submit documentation or records requested by an ADR but should only be utilized if you disagree with the initial claim determination.
The process whereby a contractor requests additional documentation after claim receipt is known as “development.” When a coverage or coding determination cannot be made based upon the information on the claim and its attachments (e.g., due to a medical review of the service/claim), contractors may solicit for more information by issuing an ADR.
Novitas Solutions specifies in the development letter or ADR, a description of the type of documentation that is needed to make the coverage or coding determination, along with the date of service. Make sure you review the ADR letter carefully as the ADR letter may request multiple types of documentation.
Once you have the requested documentation/records, submit/return:
- The original ADR request as the cover sheet to the records/documentation
- The supporting documentation, or requested medical records, with the ADR letter
- Fax to number referenced in the ADR
- Fax each ADR request separately
- Do not exceed 200 pages
- Submit to address referenced in ADR
- Submit multiple request with ADR separating each record
- Submit only documentation for date of service and procedure code requested on the ADR. If the information requested is not received within 45 days, the claim will deny.
In order to expedite the processing of claims, redeterminations, documentation requests, etc., please make sure you are submitting documents to Novitas using the correct forms. When an incorrect form is submitted or any alterations are made to the form, it is difficult for Novitas to identify the purpose of the request. By following the correct process, requests are handled more expeditiously, which helps reduce administrative costs for both Novitas and providers.
Not sure which form to use? A forms decision tree along with tutorials is available on the Forms Page (JHA) (JHB) of the Novitas website. A link to the decision tree (which includes available tutorials) is located directly under the heading for each set of forms. So, depending on what you are trying to do, the Forms Page, decision trees and tutorials will assist you in choosing and utilizing the correct form. Using the correct form will eliminate processing/review delays caused by submitting the incorrect form.