Additional Documentation Requests (ADR)

3.2.3.1 - Additional Documentation Requests (ADR) (Rev. 13821; Issued:06-09-26; Effective: 02-26-26; Implementation: 02-26-26) This section applies to MACs, RACs, SMRC, CERT, UPICs, and the Investigations Medicare Drug Integrity Contractor (I-MEDIC) as indicated. In most reviews, the MACs, CERT, RACs, SMRC, and UPICs are unable to make a determination on prepayment or post-payment claims they have chosen for review based upon the information on the claim, its attachments, or the billing history found in claims processing system (if applicable) or the Common Working File (CWF). In those instances, the reviewer shall solicit documentation from the provider or supplier by issuing an ADR. The MACs, CERT, RACs, SMRC, and UPICs shall specify in the ADR only those individual pieces of documentation needed to make a determination. When reviewing documentation, the reviewer shall give appropriate consideration to all documentation that is provided in accordance with other sections of this manual. The MACs, RACs, and SMRC shall also support soliciting documentation from the provider or supplier via Electronic Submission of Medical Documentation (esMD). The contractors shall send an Electronic Medical Documentation Request (eMDR) via esMD to those providers/suppliers that have registered to receive the request electronically. The contractors are encouraged to explore other ways to send eMDRs electronically (e.g.,, using direct exchange, clearinghouses, state Health Information Exchange (HIEs)). Providers interested in submitting documentation via esMD can find information on the CMS esMD website at http://www.cms.gov/esMD. The UPICs and I-MEDIC are authorized by CMS to use Kiteworks for purposes of facilitating the secure exchange of records and information with providers and suppliers (see Subsection 3.6.4 – Notifying the Provider for additional information).