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January 30, 2018 - Revised: 06.13.19

How to Submit "Documentation" Requested by Part A Medical Review

Please follow the Submission Protocol below if you are contacted to provide additional documentation for an easily resolvable denial.

When submitting documentation for multiple claims, it CANNOT be sent in the SAME fax transmission. These documents MUST be submitted SEPARATELY (at different times of the day/using different fax machines) in order to ensure receipt of the documents to the proper location. If you are submitting via the Portal, access Secure Forms and follow the same submission procedure below. ***DO NOT SEND USING A REDETERMINATION FORM***

Fax Cover Sheet (Page 1) Must be a blank page (no numbers) and can ONLY contain the following statement ***Part A MR Additional Documentation Requested***

Fax (Page 2) ***Provide the DCN, beneficiary name and date of service on this page only. Include the number of pages contained within the fax transmission and a staff contact ***

Fax (Page 3, etc.) ***Provide ONLY the documentation requested***

***This is a courtesy call and CGS may not always call to request this type of documentation***

Providers that have been contacted and given the opportunity to submit documentation for an easily resolvable denial must do so by COB 4pm EST within 2 Business Days of the contact. In order for the documentation to be reviewed, it is critical that the specific instructions outlined are followed.

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