LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


Corporate

Print | Bookmark | Email | Font Size: + |

Additional Documentation Request (ADR) Process

WHAT IS AN ADR? – When a claim is selected for review  or when additional documentation is needed to complete the claim, an ADR letter is generated requesting documentation and/or medical records be submitted.  The response must be submitted within a specified time frame to the requesting contractor identified on the letter for review and payment determination.  An ADR may be sent by CGS, Zone Program Integrity Contractors (ZPICs), Recovery Audit Contractors (RAC), Supplemental Medical Review Contractors (SMRCs), the CERT contractor, etc.

WHY AN ADR? – Any claim submitted to Medicare contractors may be selected for an additional documentation request (ADR). Claims may be selected when elements on the claim match the parameters of a pre-payment edit. To assist you in determining the types of documentation needed, we have provided you with an online tool which allows you to enter the CGS or UPIC ADR number. You will receive specific information based on your individual ADR number along with additional resources to make creating your response easier.

WHERE DO YOU FIND THE ADR NUMBER? – CGS places the 3-digit ADR number just below the claim line details. The UPICs place the number at the end of the documentation requirements section of the letter.

An ADR may also be sent for a post-pay review by a Medicare contractor. The information being provided in this section currently pertains to pre-payment ADRs only.

ABOUT THE ADR LETTER: – When you receive an additional development request (ADR) letter, the Medicare contractor is providing you with a specific list of items billed on the claim and the types of documentation needed to verify that items submitted on your claim meet policy requirements, are coded correctly, and/or are paid based on Medicare guidelines.

HOW TO RESPOND TO THE ADR LETTER: – When responding to the ADR letter, it is important that you fully understand what has been requested and when it must be returned to the contractor. Note: The timeline for your response varies between CGS and the UPICs. You must also package and submit the information correctly. Proper labeling and submission is critical to ensuring your response is processed promptly and accurately. To assist you, CGS has provided a sample letter below which highlights important information you need to know when responding to a CGS request for additional documentation. (Fig 1 and Fig 2)

(Fig 1)

Image of an ADR letter with the following information emphasized: 1. Important – Put this page on top of the information you return to us. 2. demonstrates placement of Medicare Claim Number, Medicare Number, and Beneficiary Name

Each letter specifies how long you have to respond. If you do not reply within that time, you may receive a partial or complete denial of your claim.

  1. ALWAYS place this page on TOP of the information you return to the Medicare contractor who requested the documentation. This is very important! At CGS, we use the QR code that is located on the first page of the letter to control your response. A coversheet is NOT needed if you are faxing your response.
  2. Review the claim information. This tells you which claim has been selected for review.

    (Fig 2)

    Image of ADR letter continued. The following information emphasized: 3. demonstration of claim information 4. demonstration of a claim line, number of services, procedure code, service dates, submitted charge and provider number. 5. ADSREF=749T 6. Demonstration of a list of requested items of documentation: dispensing order, detailed written order, medical records

  3. This section provides you with the claim that is being reviewed.
  4. Review the specific claim line information which shows what you billed and how you billed it.
  5. The ADS REF number is the ADR number. You can use this 3-digit number to search through our online tool to provide you with additional ADR information. Simply enter the ADS REF (ADR) number identified on your letter and the system will return additional information to support your response to the ADR letter.
  6. This section details the specific information requested to support our review and payment decisions.

THE CORRECT WAY TO RETURN YOUR DOCUMENTATION:

  1. Remember: You have a set amount of days from the date of the letter to provide your documentation. Refer to your request letter for the specific time frame.
  2. Always return your documentation to the Medicare contractor identified in the ADR. This information will normally be in the return address and/or in the body of the letter. Since different contractors may use very similar-looking letters, pay close attention. Sending a response to the wrong contractor could result in significant problems in getting your claim processed promptly and accurately.
  3. Always place the ADR letter as the cover sheet ON TOP of your documentation. The QR code is often used to help some contractors process your claim information.
  4. Clearly identify the documentation you have returned:
    1. Be sure to provide all requested documents. If your ADR letter requests six (6) documents, please be sure your response contains all six requested documents.
    2. If you need additional information on the kinds of appropriate documentation needed, you are encouraged to use our online ADS REF (ADR) tool. When you enter the ADS REF (ADR) number located on your letter, you will receive additional information about the type of review your claim is undergoing as well as additional resources specific to your review which may help in determining which documentation requirements must be met.
    3. Make sure your documentation is clear and legible.
    4. Make sure to only send 1 response with your documentation. That response will be used to make the claim decision.
    5. Always send separate responses for each claim and never combine them.
    6. You may return your documentation using a variety of methods. Your options are included in your ADR letter, so refer to the letter for any specifications from the requestor.

COMMON MISTAKES YOU SHOULD AVOID:

  • Never use your own cover sheet instead of the ADR letter. Forms you create to use as a cover sheet are not recognized by our system and may result in delays in routing your response appropriately. Using the ADR letter as the cover sheet will facilitate appropriate routing of your response.
  • Never omit requested information.
    • All information requested must be returned otherwise the response may be incomplete and result in a denial.
  • Never combine multiple requests into a single response. Combining documents for multiple requests delays your review and may result in a denial. Documentation that includes multiple beneficiaries will need to be split and may be difficult for the contractor to detect. This could result in claim denials if the contractor is unaware that multiple responses are in the same document.
  • Never send original documents. Always send a clear copy of the requested information. Medicare contractors will not return your documents following review of your information.
  • Don't send your response to the attention of a person or department, as you might not have the most up-to-date information and delays could occur. Contractors are able to direct your response appropriately based on the information on the ADR letter.
  • Never miss your deadline. Claims will be automatically denied if a timely response is not received. Medicare contractors may decide to reopen your claim, but are not required to. If a reopening is done, you will receive notification on your remittance notice with a new decision.
  • If you are missing the ADR letter and cannot provide it as the cover sheet, please clearly indicate "ADR Response" and include the following critical information on your cover sheet: Medicare Number, claim number, and dates of service on the claim.

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved