When your ADR letter is from our Medical Review Department, you may use our web portal, NGSConnex, to return your documentation; this is done electronically.

If you receive a Medical Review ADR for a claim that you have submitted to National Government Services it is important that you:

• Respond in a timely manner.
• Include all records necessary to support the services for the dates requested.
  • NGSConnex will accept documentation in .doc, .xls, pdf, jpg or .txt format.
    • Video or audio files are not accepted.
  • There are no limits on the number of attachments you may include with your response.
    • It is recommended that you limit the size of the attachment to 25 MB.

Refer to Respond to ADR for complete instructions.

CBRs provide comparative data on how an individual provider compares to other providers. The data looks at billing patterns for these services. The CBR offers the results of statistical analyses that compare an individual provider’s billing practices for a specific code with the billing practices of that provider’s peer groups as well as national averages.

If you received a CBR, it simply means that through data analysis National Government Services has identified your billing as being significantly different when compared to your peers. You may contact the Medical Review Case Management team with any questions or concerns regarding your CBR. Use the email address found within your CBR to contact a Case Manager.  

View our YouTube video Comparative Billing Reports - Making the CBR work for you for more information.

ADR letters are mailed to either the “Pay To” or the “Practice Location” address that the provider has designated on their enrollment application to National Government Services. Any changes to the “Pay To” or “Practice Location” address must be submitted via PECOS or by completing the 855 enrollment application for a change of information. 

Providers should have processes in place to ensure that proper staff is receiving and responding to the Medical Review ADRs in a timely fashion to avoid denials due to non-response.

You are now able to update your Part B enrollment by adding contact information in the newly added MRCA section of the PECOS/Enrollment application. Updating your enrollment with this information will help our Medical Review staff in the event there are any questions or concerns during the review process.

View our YouTube video MAC Medical Review Best Practices: Updating Your Contact Information for more information.

You can avoid delays in mailing by responding to ADRs in NGSConnex. Pre-payment review ADR letters are visible in NGSConnex. Providers can simply upload documents electronically for a quick and efficient response.

Refer to Respond to Medical Review Additional Documentation Requests for complete instructions.

You can submit the request in two ways. NGSConnex is the preferred method. You can also request an appeal by mail. If you submit the redetermination via mail, please ensure you complete the redetermination form, located on our Forms page. If you submit via NGSConnex, follow the instructions within the NGSConnex User Guide, Initiate a Search for an Appeal/Reopening Request. Be sure to follow the Levels of Appeals and Time Limits for Filing appeal guidelines.

When it’s determined that a physician/supplier has been overpaid, a refund request demand letter is sent to the physician/supplier. Timely reimbursement is required to avoid the overpayment accruing interest. Visit Refunds and Overpayments for complete instructions.

Education is an important component of the TPE review process. You can reach out to the Medical Review Case Management Team at any time with questions, concerns, or to schedule an educational call. The email address for the Case Management Team can be found on your original notification letter as well as the TPE results letter.

• Jurisdiction K: JKBCaseManagement@elevancehealth.com
• Jurisdiction 6: J6BCaseManagement@elevancehealth.com

You are able to see the reason why your claim was denied several ways. The most in-depth rationale can be found in the FISS DDE on page 04. You can also find your denial reason in NGSConnex, on your Remittance Advice, and at the end of the round on your Results Letter via the denial code column. View the FISS/DDE Provider Online Guide for additional guidance.

The Provider Contact Center can assist with general Medicare information and billing questions. Please have this information ready when you call: NPI, PTAN and last five digits of your TIN.

The numbers are state specific. Please see below:

• For Connecticut, Maine, Massachusetts, New Hampshire, New York, Vermont and Rhode Island: 888-855-4356
• For Illinois, Minnesota and Wisconsin: 877-702-0990

Address changes must be made within 90 days by completing a Change of Information electronically through the PECOS system (recommended) or by submitting the changes on a CMS-855A: Medicare Enrollment Application – Institutional Providers. The provider address that is used for Medical Review correspondence is found in Section 2: Identifying Information, C: Correspondence Address. An excellent resource for providers can be found at: PECOS Enrollment Tutorial - Change of Information for an Individual Provider. Please also verify that you have submitted any required documentation to your state as well. In addition, assistance is available by calling the Provider Enrollment area at the following numbers: 855-834-5596 (Jurisdiction 6) and 855-593-8047 (Jurisdiction K). Additional processing guidance can be found in the CMS-IOM Publication 100-08, Program Integrity Manual, Chapter 10 – Medicare Enrollment.

After MR makes their payment decision on an ADR request, the claim cycles through the edits of the CWF including a variety of checks for eligibility, other primary payers, and edits that ensure billing requirements for specific bill types have been met.  When an issue or concern is identified, the claim may reject or deny, overriding the MR decision.  In these cases, the CWF concern must be addressed and corrected (if correctable) before the MR decision can be applied to the claim and prior to giving the provider their appeal rights on the MR decision. Please call the NGS Provider Contact Center at the number listed in the Resources > Contact Us section of our website for assistance in determining the reason for rejection or denial. Upon resolution of the CWF issue, the MR decision is applied to the claim and provider appeal rights are restored.

In most cases this is an issue with timing. The mainframe systems are set to deny the claim when the provider fails to respond within 45 days of the request for documentation. If the provider responds close to the timeframe during which the documentation is due, the mainframe systems may not be updated to show the documentation has been received. If MR gets the documentation after the 45 days but prior to 120 days having passed, the claim will be reopened, the documentation will be reviewed, and a new remittance will be issued. In NGSConnex, we display a list of claims selected by Medical Review for prepayment review. In the Details, we display a ‘Documentation Receipt Date’ to indicate the date we received the documentation; however, if the provider is responding to a MR ADR that is not listed (i.e., post payment MR ADR, etc.) we would not display this information. For information on how to check the status of ADRs, visit the NGSConnex User Guide.

The detailed instructions on how to respond to an ADR not in the list are outlined in the NGSConnex User Guide. Screenshots and instructions are provided.

If MR gave a revised decision, appeal rights for that claim start when the revised decision finalizes.

The recoupment process stops during appeal. Once the appeals department has a request for redetermination, they contact the ORU. If an appeal is not requested, the recoupment process continues. You should stop getting letters if the claim pays in appeals. Recoupment requests will resume if the redetermination is not favorable.

According to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4:

“Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies. For example, if the physician’s authenticated documentation corroborates the nurse’s unsigned note, and the physician was the responsible party per Medicare’s payment policy, medical reviewers would consider signature requirements to have been met. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.”

Note: Scribes are not providers of items or services. When a scribe is used by a provider in documenting medical record entries (e.g. progress notes), CMS does not require the scribe to sign/date the documentation. The treating physician’s/NPP's signature on a note indicates that the physician/NPP affirms the note adequately documents the care provided. Reviewers are only required to look for the signature (and date) of the treating physician/nonphysician practitioner on the note.

CMS: Visit Listserv, or you can sign up at the bottom right of any CMS page to receive email updates.

NGS: Visit Subscribe for Email Updates. You can sign up by jurisdiction (J6 or JK) and choose between Part A, Part B, HH+H and FQHC.