What recourse do we have when a claim has been denied by the SMRC for no receipt of documentation requested?
Noridian is the nationwide SMRC who conducts medical reviews as directed by CMS. If you have received a denial for no receipt of documentation requested you would need to do the following:
- Submit documentation to the Medicare Administrative Contractor (MAC), who issued the demand letter for overpayment within 120 calendar days of the demand letter.
- This situation is considered a reopening and the MAC will send the submitted information to the SMRC for a re-review decision.
- The SMRC has 60 days to make a decision and will mail a letter to the supplier with their findings to pay the claim or outline why the claim is being denied.
- The SMRC will also notify the MAC of the payment or denial decision.
- The MAC will then adjust the claim and a remittance advice with the adjustment results will be generated.
- If a claim remains denied, you have the right to appeal the SMRC decision.
The SMRC website can provide you with additional information about their medical review process and how to respond to an Additional Documentation Request (ADR).
Article by Beth Cobb
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system.
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.