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Printed Date: 9/22/2015
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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Last Updated: 07/17/2020