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TPE ProcessMedical Review Additional Development Request (ADR) Process Postpayment Review

WHAT IS AN MR ADR? – When a claim is selected for medical review, a medical review additional documentation request (MR ADR) is generated requesting medical documentation be submitted to ensure payment is appropriate. Documentation must be received by CGS within 45 calendar days for review and payment determination.

WHY AN MR ADR? – Any claim submitted to CGS may be selected for medical review and generate an MR ADR. Claims may be selected when elements on the claim match the parameters of a postpayment edit established by CGS. A current list of postpayment edits can be accessed from the Part A Medical Review Activity Log.

The information below will help ensure that necessary steps are taken to submit documentation timely and avoid claim denials as a result of the MR ADR process.

  • Checking for MR ADRs
    • United States Postal Service (USPS)
    • Electronic Submission of Medical Documentation (esMD)
  • Preparing Your Documentation
  • Submitting Your Documentation
  • Receipt of Documentation
  • Review of Documentation
  • ADR Outcomes
  • ADR Resources

Checking for MR ADRs

myCGS Portal

Registered users of the myCGS portal may identify claims selected for postpayment review and access the associated MR ADR letter. Please reference the myCGS: Respond to MR Post-Pay ADRs article or the myCGS User Manual for additional information.

United States Postal Service (USPS)

Requests for additional documentation are mailed to the provider mailing address on file in FISS (i.e., the correspondence address indicated in section 2C of the CMS-855A enrollment form/PECOS). Please ensure the following:

  • The mailing address on file is valid.
    • If you do not know the mailing address on file, please contact the credentialing staff at your facility or the Part A Provider Contact Center at: 866.590.6703.
    • Corrections to the mailing address on file must be completed through the Provider Enrollment process (i.e., the CMS-855A enrollment form/PECOS). Please note: CGS correspondence other than MR ADRs is also sent to this address.
  • Develop a process for routing the ADR request to the person(s) responsible for submission that is timely and effective.
  • Inform your staff responsible for receiving the ADR letter and submitting the required documentation for review.
  • Please include the ADR letter with the documentation that you send for review.
  • Authorization for the release of the information is included in Federal Law regulations reference 42 CFR 411.24(a), 424.5(a)(6) and 44 USC 3101.

Electronic Submission of Medical Documentation (esMD)

For more information on the esMD process, refer to the CGS Electronic Medical Record Tips and Electronic Submission of Medical Documentation (esMD) Overview Web pages.

Preparing Your Documentation

When preparing your documentation, submit a copy of the ADR letter and cover sheet with each appropriate ICN/DCN to separate applicable documentation for review.

If you are responding to multiple MR 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.

CGS recommends providers organize the medical documentation in the order indicated on the specific edit code's documentation requirements checklist. This will assist CGS in reviewing your documentation more efficiently and will expedite the review process.

Providers should submit the necessary documentation to support the services for the billing period being reviewed. This may include documentation that is prior to the review period, such as admission records, physician records etc.

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.

Submitting Your Documentation

Documentation may be received by CGS either via myCGS, esMD, Fax, US Mail or on CD/DVD.

Submit your documentation so that it is received by CGS on/before 45 days, specific date is provided in the ADR Notice Letter. Ensure that you allow ample time for mailing, and processing of the documentation when received. This will prevent the claim from inadvertently denying. Mail to the address that appears in the ADR Notice Letter:

J15 Part A Medical Review
CGS Administrators, LLC
PO Box 20021
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 using myCGS to submit your documentation. If using FedEx/UPS/Certified Mail, use the address below:

CGS Administrators, LLC
J15 Part A Medical Review
26 Century Blvd STE ST610
Nashville, TN 37214-3685

myCGS is a free web portal that allows you to submit your ADR documentation directly to CGS and will help to ensure a timely response to an MR ADR. For more information on submitting MR ADR documentation via myCGS, refer to the myCGS User Manual: Forms information and the myCGS MR ADR article. myCGS also provides a secure message confirming receipt of the documentation, and a second message confirming it was accepted.

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 "Submitting Medical Records through esMD: Important Information" Web page.

CGS will also accept documentation submitted via Fax (1.615.664.5941).

RECEIPT OF DOCUMENTATION – Providers may monitor receipt of documentation by CGS through the delivery method selected (e.g. USPS proof of delivery signature record, fax transmission verification report).

REVIEW OF DOCUMENTATION – Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements. Additional information is found at: Website Website

ADR OUTCOMES – Possible outcomes of the MR ADR include affirmation of the original payment in full or denial of the payment (in part or in full). If any part of the claim is denied, an overpayment is assessed, and funds are recouped from the provider. The final demand letter will be sent by the Overpayment Recovery department to the physical address or the remittance advice may be referenced. 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 within 120 days of the denial 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.



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