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Postpayment Medical Review Results Letter

Upon receipt of Medical Review Additional Development Request (MR ADR) documentation a CGS nurse reviewer will examine the medical records submitted based on the requirements associated with the focus of the review for coverage and payment determination. CGS has 60 days from the date the documentation is received to review the documentation and make a payment determination. Possible outcomes of the MR ADR include affirmation of the original payment in full or denial of the payment (in part or in full). A results letter including allowed or denied claims with estimated overpayment amounts if applicable will be delivered.

MR
Affirmation of the original payment in full, no further action required.
Denial of the payment (in part or in full) containing a “Claim Decision Reason” section outlining the Denial Reason Code and granular detail summarizing the cause for the partial or full denial. May request Redetermination within 120 days of the Overpayment Demand Letter.
56900 Requested documentation not received/received untimely. May request 56900 Reopening and submit medical documentation for review within 120 days of the Overpayment Demand Letter.

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