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Additional Development Request (ADR) & Reopenings

If you receive a Medical Review Additional Development Request (ADR) for one or more claims that you have submitted to Medicare Part B for payment, it is important that you comply with the following instructions.

  • Provide the documents listed on the ADR and any related physician’s orders or intent to order. Make sure the physician’s signature is legible or include an attestation of signature.
  • Include a copy of the ADR with your documents.
  • Cahaba accepts medical records sent in by:
    • Mail
    • Fax: 1-855-356-0903
    • CD
    • Electronic Submission of Medical Records (esMD).  See below for additional information.
  • When sending in multiple claim ADR responses, be sure to pair each ADR letter with the corresponding documentation. Pairing these documents ensures the documentation for each request letter is correct for each date of service requested.
  • Return your ADR response to Cahaba within 45 calendar days of the ADR letter request. The claim will automatically deny by day 46, if a response has not been received.
  • Once ADR responses are received, CMS requires Cahaba to complete medical review of the documentation within 30 days. Do not resubmit ADR responses to Cahaba.
  • Do not submit replacement/duplicate claims for the ones pending in medical review. The submission of replacement/duplicate claims will result in claim denial, rejection or recoupment and will prolong the medical review process. When the claim is finalized, the claim will have paid in full or part, or denied. If you disagree with the decision, you can request a redetermination/1st level of appeal within 120 days of the determination (date on the remittance advice).

Electronic Submission of Medical Documentation (esMD)

Cahaba accepts electronic submission of medical documentation. The esMD is a system that will allow providers/Health Information Handlers (HIHs) to submit medical documentation over secure electronic means. In order to participate in esMD, providers must obtain access to an esMD gateway. To obtain access to a gateway, providers can:

  • Build a gateway, or
  • Procure gateway services from the HIH of their choice A Health Information Handler is any organization that handles health information on behalf of a provider. Many providers already use HIHs to submit claims, provide electronic health record systems, etc. These HIHs are often called claim clearinghouses, release of information vendors, Health Information Exchanges, Electronic Health Record vendors, etc. Please refer to the link below for HIHs that are CERTIFIED by CMS to offer esMD services:

Health Information Handler

http://cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Which_HIHs_Plan_to_Offer_Gateway_Services_to_Providers.html

For more information regarding the esMD process, please refer to the CMS website at http://www.cms.gov/esMD.

 

Medical Review Part B Reopenings

 

Cahaba sends providers additional development request letters (ADR) and/or letters with an attached spreadsheet requesting medical records.  By day 46, if the documentation needed to make a medical determination is not received, the claims may deny as records were not subitted timely.

You have the right to submit a request for a medical review reopening. Medical Review Reopenings should be submitted to Medical Review with a cover letter indicating it is a reopening. When mailing multiple claim ADR responses, be sure to pair each ADR letter with the corresponding documentation. Pairing these documents ensures the documentation for each request letter is correct for each date of service requested.

Send the request(s) to the appropriate address below:

Alabama Part B Redeterminations/Reopenings
Post Office Box 6169
Indianapolis, IN 46206
 
Georgia Part B Redeterminations/Reopenings
Post Office Box 6169
Indianapolis, IN 46206
 
Tennessee Part B Redeterminations/Reopenings
Post Office Box 6169
Indianapolis, IN 46206
 

CMS guidelines allow contractors the time frame of 60 days to complete the review from the date on which the last of the requested medical records is received.

Cahaba is requesting that providers pay close attention to the requested medical documentation items listed in the record request and submit all requested documentation supporting the services rendered. Receipt of claim documentation that is incomplete may slow down the processing of the claim or may result in a denial.

 

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