I received a prepayment review letter from Medical Review requesting supporting documentation for a claim. What form should I use when returning the requested information?

Return your documents and a copy of the Additional Documentation Request (ADR) letter with a completed 
Medical Review ADR Response Cover Sheet form. Use one ADR Response Cover Sheet form for each ADR letter/claim. Use of other forms may slow down the processing of your documentation.  

If your claim was denied with remittance advice remark code RARC M127 because the information requested by Medical Review was not returned within 45 days of the ADR letter date, please use the Medical Review ADR Response – Late Submission Form.

For more information about responding to ADRs, see our article Medical Review: Additional Documentation Requests (ADRs).

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Provider Contact Center: 888-355-9165

IVR: 877-288-7600

TTY: 877-715-6397

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