| (a) If necessary to determine whether a claim is payable,
an MCC may, within 30 days of receipt of a clean claim, request additional
information from the treating preferred provider. The time to request
additional information may be extended as allowed by §21.2819(c)
of this title (relating to Catastrophic Event). An MCC may make only
one request to the submitting treating preferred provider for information
under this section.
(b) A request for information under this section must:
(1) be in writing;
(2) be specific to the claim or the claim's related
episode of care;
(3) describe with specificity the clinical and other
information to be included in the response;
(4) be relevant and necessary for the resolution of
the claim; and
(5) be for information that is contained in or in the
process of being incorporated into the patient's medical or billing
record maintained by the preferred provider.
(c) An MCC that requests information under this section
must determine whether the claim is payable and pay or deny the claim,
or audit the claim in compliance with §21.2809 of this title
(relating to Audit Procedures), on or before the later of:
(1) the 15th day after the date the MCC receives the
requested information as required under subsection (e) of this section;
(2) the 15th day after the date the MCC receives a
response under subsection (d) of this section; or
(3) the latest date for determining whether the claim
is payable under §21.2807 of this title (relating to Effect of
Filing a Clean Claim).
(d) If a preferred provider does not possess the requested
information, the preferred provider must submit a written response
indicating that the preferred provider does not possess the requested
information in order to resume the claims payment period as described
in subsection (c) of this section.
(e) An MCC must require the preferred provider responding
to a request made under this section to either attach a copy of the
request to the response or include with the response the name of the
patient, the patient identification number, the claim number as provided
by the MCC, the date of service, and the name of the treating preferred
provider. If the MCC submitted the request for additional information
electronically in compliance with federal requirements concerning
electronic transactions, the treating preferred provider must submit
the response in compliance with those requirements. To resume the
claims payment period as described in subsection (c) of this section,
the treating preferred provider must deliver the requested information
in compliance with this subsection.
(f) Receipt of a request or a response to a request
under this section is subject to the provisions of §21.2816 of
this title (relating to Date of Receipt).
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