The process whereby a contractor requests additional documentation after claim receipt is known as "development". When coverage or coding determination cannot be made based upon the information on the claim and its attachments (i.e., due to a medical review of the service/claim), contractors may solicit additional information from the provider by issuing an Additional Documentation Request (ADR). Highmark Medicare Services will specify in the development letter or ADR the specific piece(s) of documentation needed to make the coverage or coding determination.

If, during a prepayment or post payment review, a development letter regarding a targeted service is sent, Highmark Medicare Services typically solicits the documentation from the billing provider, but may solicit documentation from other entities (third parties) involved in the beneficiary's care on an as-needed basis.

Providers selected for review are responsible for submitting requested medical records or other supporting documentation to the contractor within established timeframes. Providers are notified that they have 30 calendar days from the date of the initial development letter to provide the requested documentation. Highmark Medicare Services has the discretion to grant an extension of the timeframes, in rare instances, based upon the provider's individual request. If the information requested is not received within 45 days, the service/claim may be denied.

Requested medical records or any other supporting documentation should be mailed to the address referenced in the development letter or ADR. The date of service (DOS) referenced in the development letter or ADR should be validated against the medical records that are sent to ensure that the dates of service correspond. Additionally, all records/pages that are pertinent to the DOS and/or establish medical necessity should be copied and sent. If legibility of the medical record is questionable, a transcription of the medical record, in addition to a copy of the original medical record, should be sent.

For medical review audits, there are two types of record requests that a provider may receive:

1. When initiating service-specific prepay review, MR notifies providers that the service/claim has been selected for review and the specific reason for such selection. This notification will occur via a system-generated ADR. The ADR serves as notification of review as well as a request for medical records. If the information requested is not received within 45 days, the claim will time out and auto-deny. 
   
   
2. When initiating provider-specific prepayment review or any postpay review (provider or service-specific), providers are notified of the following:
   
   
   • Selection for review and the specific reason for such selection;
   • Whether the review will occur on a prepayment or postpayment basis; and
   • The list of claims and/or services for which medical records are required.
     

For responses to development that are received within the 45-day timeframe, Highmark Medicare Services will complete the review and notify the provider and beneficiary, if indicated, of the claim determination within 60 days of receiving the documentation.