General Information
In certain circumstances, National Government Services or other contractors working under the CMS may need to request additional information with regard to claims submitted to the Medicare Program. The requests for additional information letters are called ADRs.
NGS or other CMS contractors may need to analyze claims to determine provider compliance with Medicare coverage, coding, and billing rules; therefore, any claim submitted to NGS can be selected for review and an ADR letter may be sent to a provider or supplier.
When a claim(s) is selected for review, an ADR letter is generated requesting medical documentation. To ensure payment is appropriate and supports the submitted charges, providers, suppliers and staff members of such shall ensure that this ADR letter is handed to the correct person within your organization so that an appropriate and complete response is submitted. Documentation must be submitted timely to NGS or other contractors for review payment determination.
Note: NGS has 30 to 45 days from the date the documentation is received to review the documentation and make a payment determination.
You may receive an ADR letter for the following circumstances:
- A claim submitted to NGS that requires clarification
- A claim submitted electronically to NGS for PWK segment
- Your provider/supplier is selected for NGS TPE Review
- A CMS Audit Contractor is reviewing Medicare claims
- CERT
- OIG
- RAC
- SMRC
- ZPIC
Listed below are some examples of the types of medical documentation used when reviewing claims. This is not an all-inclusive list.
- Certificates of medical necessity
- Clinical evaluations
- Consultations
- Home health records
- Hospital records
- Imaging reports
- Laboratory reports
- Nursing home records
- Office records
- Operative reports
- Physician evaluations
- Physician orders
- Procedure reports
- Progress notes
- Pathology reports
- Physician’s office notes/records
- Supplier/lab/ambulance notes include all documents that are submitted by suppliers, labs, and ambulance companies in support of the claim
- Any information that supports services billed
Related Content
- The Social Security Act, Section 1833(e) - Medicare contractors are authorized to collect medical documentation. The Act states that no payment shall be made to any provider or other person for services unless they have furnished such information as may be necessary in order to determine the amounts due to such provider or other person for the period with respect to which the amounts are being paid or for any prior period."
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.2, Verifying Potential Errors and Tracking Corrective Actions, "when requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to the providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."
Revewed 9/26/2024