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April 24, 2023

Additional Documentation Requests (ADRs) Process: What to Send

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. We highly recommend that each facility has 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 automatically deny on the 46th day for non-receipt of documentation (denial message-56900).

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 prepayment or postpayment edit established by CGS.

CHECKING FOR MR ADRs USING FISS – When a claim is selected for an MR 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.

USING THE myCGS DASHBOARD TO CHECK FOR MR ADRs AND SUBMIT DOCUMENTATION – The myCGS MR Dashboard is another option for you to quickly identify whether you need to respond to MR ADRs. Refer to the myCGS User Manual: Medical Review section for step-by-step instructions.

PREPARING YOUR DOCUMENTATION – When preparing your documentation, please include a copy of the ADR letter with each claim to clearly separate the documentation for review. This will ensure the documentation is matched to the appropriate patient and claim. Please ensure you also include a cover sheet with a designated point of contact (name, email, telephone number) with all records submitted in response to each ADR.

For Targeted Probe and Educate (TPE) claims, continue to submit a copy of the ADR letter and include a completed TPE ADR Documentation Cover Sheet with each claim submitted. Ensure the provider contact name and phone number (you may also include an email address) are completed on this form. This will improve the accuracy and timeliness of both the submission and the review process. The medical review department may provide a courtesy call to the provider contact listed to request additional documentation for an easily curable error identified during the review process to prevent a claim denial for missing documentation.

If you are responding to multiple MR ADR requests, clearly separate the documentation for each claim with a copy of the ADR letter and/or send separately. Faxed, myCGS and esMD submissions can only contain one beneficiary per claim and date of service. Multiple responses sent together, but not separated, may result in the documentation being imaged as one claim and could cause unnecessary 56900 denials for missed documentation.

WHAT TO SUBMIT – A current list of edits with documentation requirements checklists, additional submission information, resources and helpful tips on preventing common denials can be accessed on the Part A Medical Review Activity Log.

When you submit records in response to a request from CGS, please do not send the entire patient chart or send multiple records in the same submission without clearly separating the documentation for each claim with a copy of the ADR letter. If you are submitting documentation in a series for the same claim, please ensure each submission contains a copy of the ADR letter and include a notation of the series on the cover letter by labeling each separate transmission. For example, if you are sending in 3 separate transmissions for the same claim and DOS, please label each submission accordingly on your cover letter (Submission 1 of 3, 2 of 3, 3 of 3).

Many ADRs will specify exactly what documentation is being requested. Medicare contractors do not base their decisions on the volume or weight of the documentation submitted. Instead, send all relevant documentation to support the medical necessity of the service in question, and send only the relevant documentation required to support the payment of the services.

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 and supports the DOS billed. For example, some reviews may require the submission of documentation that was completed prior to the review period, such as an Individualized Treatment Plan (ITP), to support the DOS billed on a cardiac rehabilitation claim. Response to an ADR may require you to contact the hospital, physician office and/or the facility where the services were provided and obtain your signed and dated physician orders, history and physical information, progress notes, plan of care, and/or other requested documentation.

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

Submit your documentation so that it is received by CGS on/before 45 days ("DUE DATE" on FISS Page 07). 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 on the ADR letter or FISS Page 07:

CGS
J15 PART A MEDICAL REVIEW
PO BOX 20021
NASHVILLE, TN 37202

IF USING FED EX OR UPS OVERNIGHT SERVICES PLEASE SEND RECORDS TO:

CGS
J15 PART A MEDICAL REVIEW
26th CENTURY BLVD STE. ST610
NASHVILLE, TN 37214

NOTE: CGS does not recommend sending your documentation overnight via FedEx 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. Using myCGS to submit your documentation is highly suggested.

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 Job Aid. 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 CMS esMDExternal Website Web page.

CGS will also accept documentation submitted via Fax (1.615.664.5941). (INCLUDE A COPY OF THE ADR LETTER AND A COVER SHEET WITH A DESIGNATED PROVIDER CONTACT).

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. Confirmation of receipt is also provided when using myCGS to submit your documentation.

REVIEW OF DOCUMENTATION – A CGS nurse reviewer will examine the medical records submitted to ensure the technical components are met and that medical necessity is supported. CGS has 30 days from the date the documentation is received to review the documentation for prepayment reviews and make a payment determination; and 60 days for postpayment reviews to review the documentation and make a payment determination.

ADR OUTCOMES – Possible outcomes of the MR 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 within 120 days of 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.

Please share this information with your billing/medical records staff.

ADR RESOURCES

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