Documentation Required
AR Guide KnowledgeRequests for medical records, orders, notes, certificates, and other clinical documentation.
Denial Decoder
Run this denial through the decoder
Enter the codes from your ERA/EOB and get this workflow with the exact CARC/RARC on your line.
Check first
Check these before anything else
- Exactly what was requested, and by when
- The payer's preferred submission channel (portal, fax, mail)
- Claim number to reference on every page
- Submission confirmation and receipt
- CARC 163 and the accompanying remark code
Verify payer-specific rules: Heads up
AR Guide knowledge
What it means
The claim is being held pending documentation the payer needs to adjudicate it — commonly medical records for medical necessity, orders or certificates for DME, or notes for specific services. These are usually submission problems, not appeals: send the requested documentation through the payer's preferred channel and reference the claim number.
AR Guide knowledge
Common causes
- Supporting documentation not sent with the claim
- Documentation sent to the wrong address or channel
- Fax or portal submission failed
- Requested certificate, order, or note never obtained
- Documentation incomplete or illegible
AR Guide knowledge
What AR should verify
- Identify exactly what documentation was requested and by when
- Check the payer's preferred submission channel (portal, fax, mail)
- Confirm the submission was received and reference the claim number
- Track the submission so it can be proven later
- Confirm the documentation covers the service dates in question
Recommended workflow
What to do next
- Send the requested documentation through the payer's preferred channel
- Reference the claim number on every page of the submission
- Track the submission and follow up if no acknowledgment arrives
- Resubmit the claim with the requested documentation if required
Don’t assume
Avoid these shortcuts
- The documentation was received just because it was sent
- A fax or portal submission succeeded without confirmation
- The payer will request the documentation twice
- The request is a denial — it is usually a hold pending documentation
- Any channel works — use the payer's preferred one
AR Guide knowledge
Documentation
- The payer's documentation request letter
- The records or certificates submitted
- Submission confirmation (fax report, portal receipt)
AR Guide knowledge
Escalation
- QA: when documentation requests are repeatedly missed, review the intake workflow
- Clinical: obtain the needed records from the provider
- Supervisor: when the payer requests documentation that does not exist or is not applicable
QA checkpoint
Confirm before closing
- Attach required documentation at initial submission
- Track documentation requests with due dates
- Keep proof of every documentation submission
AR Guide knowledge
Related guides
Reference
Related codes
CARCs
CARC163Attachment/other documentation referenced on the claim was not received.CARC50These are non-covered services because this is not deemed a 'medical necessity' by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.CARC16Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Source & review
References
AR Guide editorial research · Last reviewed Aug 15, 2026 · Reviewed. General practice guidance — not official payer or standards documentation. Payer-specific requirements must be verified with the payer.
About this guidance: Note