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November 4, 2014

Additional Documentation Requests (ADRs): What to Send

CGS requests medical records for some services prior to processing claims. A good rule of thumb is to send records that support the service and diagnosis (or diagnoses) submitted on the claim as well as the medical necessity for the services.

When you send records in response to a request from CGS or from another medical review contractor (including the Comprehensive Error Rate Testing (CERT) contractor or Recovery Auditor), please do not send the entire patient chart. Many requests will specify exactly what documentation is being requested, or for repeat requests, what documentation was missing from the initial submission. Medicare contractors do not base their decisions on the volume or weight of documentation submitted. Instead, send all relevant documentation related to the service in question, and send only the relevant documentation. You will find services and claims being reviewed by CGS and outcomes from these reviews, as well as coverage guidelines, claim submission guidelines, and most common types of documentation that may apply, on the CGS Medical Review web page (scroll down to access information on probe medical reviews, complex medical reviews, and other helpful articles).

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

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