A provider responds to an ADR request with the related documentation. esMD allows providers to send an unstructured document electronically to the RC.
The esMD program’s initial focus was to support HIHs in sending unstructured documents as responses to Additional Document Requests (ADRs). Once the esMD system was developed to handle exchanging unstructured documents, esMD started supporting more use-cases which involve the exchange of unstructured documents. This required minor changes in the file parameters (different content type values were used). These are referred to as Lines of Business (LoBs) and currently include:
Once an initial claim is denied for payment by Medicare, participating providers and suppliers can appeal. The esMD system enables providers to submit first level appeal requests electronically in PDF format to review contractors.
If a First Level Appeal is denied, participating providers and suppliers can appeal a second time. esMD allows providers to submit second level appeals request electronically in a PDF format.
Providers may want to request a discussion with a RA to discuss the results of their review. esMD allows providers to submit Recovery Auditor Discussion Requests electronically in PDF format to RAs.
CMS introduced the Prior Authorization demonstration for Power Mobility Devices (PMD) in Nov 2011. Under this demonstration, all providers in the states covered by the demonstration are required to obtain authorization prior to ordering PMDs that fall under the demonstration. The demonstration has been expanded to include Certain Durable Medical Equipment, Prosthetic, Orthotics, Supplies (DMEPOS) Items, Non-emergent Hyperbaric Oxygen, Repetitive Scheduled Non-Emergent Ambulance Transport.
ADMC is a voluntary program that allows suppliers and beneficiaries to request prior approval and determine, in advance of delivery, whether the purchase of a DME item would likely be covered. Review Contractors who are participating in the ADMC functionality do so on a voluntary basis.
Providers and Suppliers who supply DME may want to request a discussion with a Qualified Independent Contractor (QIC) regarding a denied claim. esMD allows providers to submit a DME discussion request electronically.