Centers for Medicare and Medicaid Services (CMS) contractors medically review some claims and prior authorizations to ensure that payment is billed or authorization is requested only for services that meet all Medicare rules. If the review results in a denied/non-affirmed decision, the review contractor provides a detailed denial/non-affirmed reason to the provider or supplier.
Historically, Medicare review contractors, including Medicare Administrative Contractors, Recovery Audit Contractors, and Supplemental Medical Review Contractors, developed and maintained individual lists of denial reason codes and statements. If you work with multiple CMS contractors, understanding the many denial codes and statements can be hard. In 2015, CMS began to standardize the reason codes and statements for certain services to ensure providers and suppliers have a more consistent experience and that claim denials are easier to understand.
Currently, review reason codes and statements are available for the following services/programs:
Additional Document Request (ADR) letters are sent via esMD as Electronic Medical Documentation Request (eMDR) letters. Document codes represent the documents to be requested from the provider, in a codified form.
The complete list of latest document codes can be found here:
Please email PCG-ReviewStatements@cms.hhs.gov to suggest a topic to be considered as our next set of standardized review result codes and statements.