Additional Development Requests

Ways to Respond to ADRs

Table of Contents

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Ways to Respond to ADRs

Each ADR letter includes all of the details you need to respond to the medical record request. The following information is contained in each ADR letter:

  • The contractor requesting the medical records (NGS or other CMS contractor).
  • The claim that the medical records is required for.
  • The reason for the medical record request.
  • Which medical records are being requested.
  • The date that the records must be received by.
  • Where to send the records.
  • How to submit the records to NGS or other CMS contractor.

It is important for you to submit all of the requested medical records in a timely manner. Do not submit records that were not requested. This delays the review process.

NGS and CMS contractors offer multiple methods for submitting the requested documentation. When you are ready to submit the documentation, please refer to the ADR letter for the offered methods of submission.

Here is a summary of the different submission methods offered by NGS. It is important to note that not all methods apply to all ADR letters. You must use the methods mentioned in each letter.

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Utilizing Paperwork Segment and esMD

The PWK segment indicates that you have submitted unsolicited documentation for NGS to review. This is often used for NOC or UC claim submissions.

For claims submitted electronically with PWK segment, the Medicare Part B Fax/Mail/esMD Cover Sheet shall be used. We ask that you use one PWK Medicare Fax/Cover Sheet for each electronic claim for which documentation is being submitted.

Important reminders: One cover sheet with documentation per transmission per beneficiary. It is also important to remember to send the additional documentation after the claim has been electronically submitted with the PWK segment.

Accurately and completely record data on the fax/mail cover sheet that relates the faxed/mailed data to the PWK Loop on the claim. Incomplete or incorrect PWK data submissions (cover sheet), will be returned.

More facts about the Medicare Part B PWK Fax/Mail/esMD Cover Sheet, can be accessed from the following:

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Electronic Submission of Medical Documentation

CMS implemented the esMD program for providers to submit medical documentation in response to requests from Medicare review contractors.

Any provider who would like to electronically submit medical documentation shall either:

  1. Build a gateway, or
  2. Procure gateway services from an HIH of their choice.

You can learn more about signing up for esMD and choosing an HIH at Electronic Submission of Medical Documentation (esMD).

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NGSConnex Portal

If you use NGSConnex to return medical documentation that was requested by our claims department, refer to NGSConnex User Guide: Respond to ADR Not in List for detailed instructions.

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Fax

Some NGS ADR letters will contain specific fax numbers based on the department that has requested the documentation.;

  • NGS ADR fax numbers may be similar, if the incorrect fax number is used for the documentation submission, this will delay claim processing. Therefore, it is important that you verify the fax number used matches the fax number on the ADR letter.
  • If a fax number is not included in the ADR letter, then faxing the documentation is not allowed.

    Note: Claim-related ADRs will not contain fax numbers. Some claim ADRs can be responded to via NGSConnex. Claim related ADRs may be mailed to the address listed on the claims ADR letter.

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U.S. Mail, FedEx, UPS

We include a direct mailing address in all of our ADR letters.

When you choose to mail your documentation, please send the original ADR to us along with the requested documentation.

  • The original ADR letter has a bar code that NGS uses for scanning purposes.
  • Retain a copy of the ADR letter for your records.
  • Send only the request documentation and no more; anything received that was not requested will cause processing delays.

Reviewed 9/26/2024