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Medical Review Additional Documentation 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 Home Health and Hospice Medical Review Activity Log Web page.

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

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 User Manual for additional information.

United States Postal Service (USPS)

Requests for additional documentation are mailed to the agency 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 agency or the Provider Contact Center at: 877.299.4500.
    • 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 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 Submission of Medical Documentation" and Electronic Submission of Medical Documentation (esMD) OverviewExternal WebsiteWeb pages.

PREPARING YOUR DOCUMENTATION

When preparing your documentation, submit a copy of the ADR letter and contact form 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 below. 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, hospice Interdisciplinary Group (IDG) review, etc.

Hospice ADR Checklist – Preferred Order

Home Health ADR Checklist – Preferred Order
  1. ADR Letter and Contact Form
  1. ADR Letter and Contact Form
  1. Signed election statement
    1. Addendum(s) (as applicable)
  1. Physician or allowed practitioner Face-to-Face documentation
    1. Actual encounter note or progress note
    2. Discharge summary from inpatient stay
  1. Plan of care with physician certification/recertifications
  1. Plan of care with physician or allowed practitioner certification/recertification
    1. If recertification, include initial certification and plan of care
  1. Physician Face-to-Face documentation (for third and later benefit periods)
  1. Interim/verbal orders
  1. Physician orders
  1. OASIS assessment
  1. IDG reviews/POC updates

    Note: include reviews for each 15-day period to cover the billing period. This may include reviews/updates that occurred prior to the billing period.
  1. Nursing visit notes
  1. Initial assessment for billing period
  1. Therapy visit notes including evaluations/re-evaluations
  1. Visit notes (nursing, social worker, chaplain, etc.)
  1. Social work visit notes
  1. Physician visit notes
  1. Aide visit notes
  1. Other relevant documentation
    1. Admission assessment
  1. Other relevant documentation
    1. Any other acute/post-acute care documentation to support home health eligibility.

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

CGS may receive documentation via US Mail, esMD, Fax, myCGS 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-HHH Correspondence
CGS Administrators, LLC
PO Box 20014
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 overnight delivery via the US Postal Service to the address above. Using myCGS to submit your documentation is also an option.

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 CGS "Electronic Submission of Medical Documentation" Web page.

CGS will also accept documentation submitted via Fax (1.615.660.5981).

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 – A CGS nurse reviewer will examine the medical records submitted to ensure the technical components (OASIS, certifications, election statement, etc.) are met, and that medical necessity is supported. CGS has 60 days from the date the documentation is received to review the documentation and make a payment determination.

A hierarchy is used to review documentation. This means that documentation is first reviewed for administrative documentation, and then medical documentation. Denials are applied according to the hierarchy; however, any additional findings will be addressed in the medical review findings notification.

Hospice Hierarchy   Home Health Hierarchy
Valid election statement and addendum(s) (as applicable) Technical components: OASIS submission, certification/orders, FTF
Technical components: certification statement, FTF if 3rd or later benefit period Homebound documentation
POC updated every 15 days Intermittent skilled nursing or therapies
Disease acuity or trajectory supports 6 month prognosis – LCD L34538: "Hospice Determining Terminal Status" Reasonable and medically necessary skilled service
Non-routine care supported Use LCD L33942: "Physical Therapy – Home Health" for guidance (when applicable)
Physician visits OASIS and coding

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 Overpayment recovery. 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.

ADR RESOURCES

Updated: 02.21.22

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