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Responding to Additional Development Requests for Information

As a part of claims processing, there are times when it is necessary to send an ADR for information needed to make a claim adjudication decision. When you receive an ADR, please read the letter completely and return the requested information as soon as possible to ensure that the time allotted is met according to the request.

Remember, as a provider and a HIPAA-covered entity, you must respond to an ADR with the minimum required information necessary to explain what was done regarding that service. NGS has seen many submissions in response to an ADR for an appealed claim that exceed 800 pages of information which appears to be a patient’s entire chart. Please know that this is not an acceptable practice. 

Submitting a patient’s entire chart or more information than necessary can delay the processing of that claim, or appeal, valid information may be overlooked due to the large volume of information submitted and most importantly, submitting more patient information than necessary to answer the question is a HIPAA violation. HIPAA legislation for privacy and security clearly states that covered entities are to only share the “minimum necessary” needed to make a determination.

In 45 CFR 164.502(b) the minimum necessary standard states:

(b) Standard: Minimum necessaryMinimum necessary applies. When using or disclosing protected health information or when requesting protected health information from another covered entity or business associate, a covered entity or business associate must make reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request.

Here are some important reminders when you are sending in documentation to support an appeal. Send only new documentation you want us to consider for the appeal

  • Consolidate multiple single files into one file, and only include the minimum required information
  • If you have already sent the documentation responding to an ADR, do not send in the same documentation for the appeal, they would be considered duplicates

As a HIPAA violation, NGS will submit information to the Department of Health and Human Services of providers continuing to submit documentation in this manner.

Responding to Additional Development Requests for Information
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