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Additional Development Request (ADR) Process

WHAT IS AN ADR? – When a claim is selected for medical review, an additional development request (ADR) is generated requesting medical documentation be submitted to ensure payment is appropriate. Documentation must be submitted timely to CGS for review and payment determination.

WHY AN ADR? – Any claim submitted to CGS may be selected for an additional development request (ADR). Claims may be selected when elements on the claim match the parameters of a pre-payment edit established by CGS. Additional information about the types of edits, and a current list of widespread edits, can be accessed from the "Overview of Medical Review" Web page.

The information below will help ensure that necessary steps are taken to submit documentation timely, and avoid having claims denied as a result the ADR process.

CHECKING FOR ADRs – When a claim is selected for an ADR, the claim is moved to a Fiscal Intermediary Standard System (FISS) status/location S B6001. Providers are encouraged to use FISS Option 12 (Claim Inquiry) to check for ADRs at least once per week. You will not receive any other form of notification for an ADR.

Your agency should have an internal process established to monitor claims selected for an ADR, and to ensure the documentation is submitted within the required timeframe. If the requested documentation is not received timely by CGS, the claim will be automatically denied.

To check for ADRs using FISS Option 12, key your NPI number, the status/location 'S B6001', and press Enter. Claims selected for ADR will appear.

ADR screenshot

FISS Pages 07 and 08 — Each claim that appears in S B6001 must be selected to identify the documentation that is being requested, as well as the timeframe by which the documentation must be received. This information is found on FISS Pages 07 and 08. These pages only appear when the claim is in status/location S B6001. Screen print FISS pages 07 and 08 for your reference. CGS requires FISS Page 07 be returned with the ADR documentation.

FISS page 07 includes the:

  • HICN of the patient;
  • dates of service on the claim;
  • document control number (DCN) of the claim;
  • mailing address to which your documentation must be sent;
  • "Due Date", which is the 45th day. However, you are required by CMS (Pub. 100-08, Ch. 3 §3.2.3.2External PDF) to mail documentation by day 30 – 15 days before the "Due Date".

Example of FISS Page 07:

ADR screenshot

Press F6 to view the entire message.

ADR screenshot

FISS Page 08 is a list of the documentation being requested. This may include initial assessments, the plan of care, physician's orders, visit notes, the certification of terminal illness and election statement (hospice), and OASIS assessments (home health). You may need to press F6 to view the complete list of requested documentation. In addition to the listed documentation, you should send any other documentation that supports payment of the services billed, even if the documentation is before or after the dates of service on the claim, but relevant to the services provided.

Example of FISS Page 08:

Screen shot

PREPARING YOUR DOCUMENTATION

When preparing your documentation, attach a copy of FISS Page 07 as the top page of your documentation to ensure the documentation is matched to the appropriate patient and claim.

CGS recommends providers organize the medical documentation in the order indicated below.  This will assist CGS reviewers in finding the necessary documentation and will expedite the review process. 

Hospice ADR Checklist – Preferred Order

Home Health ADR Checklist – Preferred Order

  1. FISS Page 7 screenprint
  1. FISS Page 7 screenprint
  1. Signed election statement
  1. Physician Face-to-Face documentation
  1. Plan of care with physician certification/recertifications
  1. Plan of care with physician certification/recertifications
  1. Physician Face-to-Face documentation (for third and later benefit periods)
  1. Interim/verbal orders
  1. Physician orders
  1. OASIS assessment
  1. IDG reviews/POC updates

Note: include reviews for each 15-day period to cover the billing period.  This may include reviews/updates that occurred period to the billing period.

  1. Nursing visit notes
  1. Admission initial assessment
  1. Therapy visit notes including evaluations/re-evaluations
  1. Visit notes (nursing, social worker, chaplain, etc.)
  1. Social work visit notes
  1. Physician visit notes
  1. Aide visit notes
  1. Other relevant documentation
  1. Other relevant documentation

If you are responding to multiple ADR requests, clearly separate the documentation for each claim. Due to CGS's process for imaging documentation, the use of rubber bands or binder clips, or mailing documentation for each claim in separate envelopes, is recommended. Multiple responses sent together, but not separated, may result in the documentation being imaged as one claim. Do not staple documentation.

Providers may include an outline or cover letter with their documentation. This can be used by CGS Medical Review staff as a roadmap, and prove very helpful to highlight key dates or documentation that supports payment of the claim. However, the cover letter cannot be used as documentation, and the documentation must support the contents of the cover letter in order to be useful.

In addition, providers may use brackets, such as [ ] or { }, asterisks (*) or underlined text in the documentation to draw the reviewer's attention to important information. However, notations should not alter, or give the appearance of altering, the documentation. The use of a highlighter is not recommended.

MAILING YOUR DOCUMENTATION

Documentation may be submitted to CGS either via US Mail, esMD, Fax or on CD/DVD.

Mail your documentation, or CD/DVD to CGS by day 30 (15 days before the "Due Date"). This 30-day timeline allows for ample mail time, and processing of the documentation when received, preventing the claim from inadvertently denying. Mail to the address that appears on FISS Page 07:

CGS J15 MAC
J15 – HHH Correspondence
PO Box 20014
Nashville, TN 37202

NOTE: CGS does not recommend sending your documentation overnight via Fed Ex or UPS. If prompt mailing of your documentation is necessary to meet the due date, CGS recommends overnight delivery via the US Postal Service to the address above.

The Electronic Submission of Medical Documentation (esMD) process may be used as an alternative to mailing your documentation. For more information on the esMD process, refer to the CGS "Electronic Submission of Medical Documentation" Web page.

CGS will also accept documentation submitted via Fax (515-471-7581).

RECEIPT OF DOCUMENTATION – When your documentation has been received by CGS, the claim is moved from status/location S B6001 to S M50MR for review. Providers can monitor the S M50MR status/location in FISS, to verify that their documentation has been received by CGS.

REVIEW OF DOCUMENTATION – A CGS nurse reviewer will examine the medical records submitted to ensure the technical components (OASIS, certifications, election statement, etc.) are met, and that medical necessity is supported. CGS has 60 days from the date the documentation is received to review the documentation, and make a payment determination.

A hierarchy is used to review documentation. This means that documentation is first reviewed for administrative documentation, and then medical documentation. At any point in the review process, if documentation is found to be missing, incomplete or insufficient, the review process ceases, and any remaining documentation is not reviewed. For example, if an error is found with the technical components of the documentation (i.e. FTF), the review stops, and the documentation is not reviewed for medical necessity (i.e. terminal prognosis).

Hospice Hierarchy   Home Health Hierarchy
Valid election statement Technical components: OASIS submission, certification/orders, FTF
Technical components: certification statement, FTF is 3rd or later benefit period Homebound documentation
POC updated every 15 days Intermittent skilled nursing or therapies
Disease acuity or trajectory supports 6 month prognosis – Hospice LCD: "Determining Terminal StatusExternal Website" Reasonable and medically necessary skilled service
Non-routine care supported Use "Physical Therapy – Home HealthExternal Website" LCD for guidance (when applicable)
Physician visits OASIS and coding

During the review, if a signature is found to be missing or illegible, or an electronic signature cannot be authenticated, the claim will be re-ADRd to you in status/location S B6001. Page 08 will show with edit 5ADR2 with a narrative indicating that additional documentation is required to support the signatures. Page 04 (Remarks) will specify the documentation being requested. The additional signature documentation must be sent to CGS within 15 days of the request. A screenprint of Page 07 should be attached to the top of the additional documentation and returned to CGS.

ADR OUTCOMES — Possible outcomes of the ADR include payment in full (P B9997), partial payment (P B9997), or a full denial (D B9997). Providers are notified of the payment determination via the FISS status/location, as well as their remittance advice. When a claim is denied with reason code 56900 indicating that the medical documentation was not received by CGS, or was not received timely, a “56900 reopening” may be requested to have the medical documentation reviewed by the Medical Review department, without utilizing the Medicare Appeals Process. All other denials for which the provider disagrees may be appealed using the Medicare Appeals Process.

ADR RESOURCES

Updated: 03.28.14


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