PAR Denials

If you receive a denial notice, please review the notice to determine the reason for the denial. The notice will have a code that will indicate the reason.

The provider may request an appeal of the case (sometimes referred to as a reconsideration or a re-open). A re-open may occur when at least one line item on a PAR has been completely denied. The provider may appeal the denial by submitting further supporting evidence that the service is justified and medically necessary. A re-open must be for the same provider, same dates of service, same line items and same number of units requested. If there are changes to these, the provider should submit a revision or a new request.

If the denial is due to lack of medical necessity and the provider disagrees with the decision, the provider may submit the PAR again to CFMC with additional information supporting medical necessity. A different reviewer will examine the PAR request and information and make a determination.

If the denial is due to non-receipt of requested additional information, the provider may submit the PAR to CFMC again with the additional information that was originally requested. CFMC realizes that at times it may take longer than ten business days for the provider to obtain the requested information. Because CFMC is required to complete a PAR within ten business days, if the requested information has not been received, the PAR must be denied. The provider can submit the information once it has been received, with the original PAR dates and if the service is found to be medically necessary the service will be approved back to the original PAR start date.