Additional Documentation Request (ADR) Overview
In general, an additional documentation request (ADR) is generated when documentation is necessary to adjudicate a Medicare claim. CGS generates two types of ADRs:
- Medical Review (MR)
- Non-Medical Review (Non-MR)
MR ADRs (Reason Code 39700)
When a claim is selected for medical review, the claim suspends to the Fiscal Intermediary Standard System (FISS) status/location S B6001 with reason code 39700 and an MR ADR is generated. An MR ADR is a request for medical record documentation that supports the medical necessity of service(s) reported on the claim to ensure compliance with Medicare's coverage, coding, payment and billing policies.
CGS must receive the documentation within 45 calendar days from the date of the request. If documentation is not received by day 46, the claim will deny.
Refer to the following resources for details:
- Medical Review Additional Documentation Request (ADR) Prepayment Review Web page
- Medical Review Additional Documentation Request (ADR) Postpayment Review Web page
- Prepayment Medical Review Additional Documentation Request (MR ADR) quick resource tool
- Postpayment Medical Review Additional Documentation Request (MR ADR) quick resource tool
Non-MR ADRs (Reason Code 39701)
Other claims may also suspend to FISS status/location S B6001 with reason code 39701 and generate a non-MR ADR. A non-MR ADR is a request for additional information necessary to adjudicate a claim that is unrelated to CGS's medical review activities. Non-MR ADRs are generated in the following situations.
- Home Health and Hospice Exception Requests - When a home health or hospice claim includes modifier 'KX' and the REMARKS field (FISS Page 04) is either blank or insufficient, CGS will generate a non-MR ADR to request documentation that clearly indicates all the circumstances and time frames to support the exception request for the untimely Notice of Admission (NOA) / Notice of Election (NOE).
- Other Medicare Contractors - CGS may generate an ADR on behalf of other Medicare Contractors (e.g., Unified Program Integrity Contractors (UPICs), Recovery Audit Contractors (RACs), and Supplemental Medical Review Contractors (SMRCs)). In this situation, follow the instructions in the ADR.
Refer to the Medical Review Contractors Web page to learn more about other Medicare contractors.
CGS must receive the documentation within 30 calendar days; however, prompt submission will expedite the processing of your claim. If the documentation is not received by day 31, the claim will process as submitted, with noncovered days/charges due to the untimely NOA/NOE.
Refer to the Requesting an Exception for an Untimely NOE Web page for additional information.
NOTE: It is important that you review the reason code narrative of the ADR (FISS Page 08). You may need to press F6 to view the full narrative. If the addresses on FISS Page 07 and Page 08 differ, send the documentation to the address that appears on FISS Page 08, instead of the CGS Nashville, TN address.
Use the myCGS portal to identify and respond to ADRs!
Updated: 06.13.22