Overview

Each year, the Medicare Fee-For-Service (FFS) Program makes billions of dollars in estimated improper payments. CMS employs several types of Review Contractors to measure, prevent, identify, and correct these improper payments. For more information about Medicare improper payments, go to paymentaccuracy.gov by clicking the link below called "Improper Payments."

Review Contractors find the improper payments by selecting a small sample of claims, requesting medical documentation from the provider who submitted the claims and manually reviewing the claims against the medical documentation to verify the providers' compliance with Medicare's rules.

Review Contractors request medical documentation by sending a paper letter to the provider. In the past, these providers had only 2 options for submitting the requested records: sending a letter or fax.

Electronic Submission of Medical Documentation System (esMD)

During Phase 1 of esMD, providers still receive medical documentation requests via paper mail but will have the option to electronically send medical documentation to the requesting Review Contractor. Phase 1 of esMD went live on September 15, 2011.

During Phase 2 of esMD, providers will receive electronic documentation requests when their claims are selected for review. CMS plans to go live with esMD Phase 2 in the future.

For a graphical depiction of esMD, see the download below called "esMD Graphic."

In addition to medical documentation requests/responses, the esMD system recently began supporting the Power Mobility Devices (PMD) Prior Authorization request process. For more information about the PMD Prior Authorization process, click the link called "PMD Prior Authorization" in the 'Related Links' section below.

Durable Medical Equipment Medicare Administrative Contractors (DME MACs) in Jurisdictions C and D began accepting Power Mobility Device (PMD) Prior Authorization requests through esMD on January 7, 2013.  The DME MAC in Jurisdiction A began accepting PMD Prior Authorization requests through esMD on January 9, 2013. The DME MAC in Jurisdiction B began accepting esMD transactions on February 22, 2013. For more information on PMD click the link called "PMD Prior Authorization" and to view a list of which HIHs offer this service, click the link called "HIHs that offer Prior Auth submission services" in the 'Related Links' section below. 

Reason Statements for Denial

CMS and the DME MACs strive to provide detailed explanations for non-affirmative prior authorization decisions. As CMS considers future enhancements, CMS and the DME MACs have created a draft list of reason statements to provide a narrative explanation of the non-affirmative decision.  CMS welcomes comments regarding these 'Proposed Reason Statements' which are available in the Downloads section below.  Please send your comments to reasonstatements@cms.hhs.gov