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March 26, 2026

Widespread Pre-Payment Medical Record Review Announcement – New Suppliers

CGS will conduct a prepayment medical record review of claims for the following six policy groups submitted by new suppliers:

  • Orthotics (lower limb, upper limb, and spinal)
  • Continuous Positive Airway Pressure (CPAP)
  • Surgical Dressings
  • Glucose Monitors
  • Diabetic Shoes
  • Ostomy Supplies

These six policy groups rank high in Comprehensive Error Rate Testing (CERT) errors for Jurisdiction B and Jurisdiction C. New suppliers are also identified by CMS (2026 Home Health Prospective Payment System (HH PPS) (90 FR 29108External Website) and Nationwide Temporary Moratoria on Enrollment of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Medical Supply Companies (91 FR 9855External Website) as often associated with high levels of fraud, waste, and abuse.

CGS will send Additional Documentation Requests (ADR) for these claims. It is important to respond to ADR letters. Federal law (Social Security Act, Sections 1815(a), 1833(e), and 1862(a)(1)(A)) authorizes the collection of this information. Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor like CGS.

Failure to provide records may result in a claim denial and referral to the National Provider Enrollment (NPE) contractor and/or Unified Program Integrity Contactors (UPICs).

The ADR letter will request the following information to support payment of the claim:

  • Treating practitioner's written order.
  • Relevant medical records that support the item(s) that is prescribed are medically necessary.
  • Any other pertinent documentation.
  • Proof of Delivery
  • Copy of Advance Beneficiary Notice (ABN) if one was obtained.

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