Prior Authorization Details

How to Find and Respond to a Prior Authorization ADR

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How to Find and Respond to a PA Pre and Post Payment ADR

The National Government Services Part A PA department generates ADRs annually to assess compliance for exempt status retention. In addition, NGS PA conducts ABN validity reviews for denied claims that hold a GA modifier. Please review each ADR carefully, as each request includes documentation to submit and specific instructions for submission. Applicable reason codes are 58BTP, 58BPP, 58PNP, 58RHP, 58VEP, 58FCP, 58SNP, 58CVP, and 5HBO1.

To avoid claim processing delays, it is important providers respond to ADRs in a complete and timely manner. Listed below are guidelines and checklists that will assist with claim submission:

  • NGS recommends responding to ADRs within 35‒40 days of letter date (CMS allows providers 45 days of the ADR date). See the ADR Timeline Calculator available on our website for help with determining the target date that the requested medical records must be received by NGS.
  • The NGS self-service portal, NGSConnex, is the preferred method for ADR response submission and allows Part A and Part B providers to respond to ADRs electronically with no need to mail or fax a response to complete the ADR process. If you are a current user of NGSConnex, click on the link for the NGSConnex User Guide for step-by-step instructions on how to submit. If you are not a current user, sign up and get started.
  • If you mail in your ADR, please send each response separately and attach a copy of the corresponding ADR. Each response must be individually bundled.
  • Include all records necessary to support the services for the dates requested.
  • Records must be complete and legible. Be sure to include both sides of double-sided documents.
  • All services must include the necessary signatures and credentials of professionals. See the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 “Signature Requirements”.

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Steps to View and Print ADRs from FISS/DDE Provider Online System

  1. Access the claims through the Claims Inquiry screen/option.
  2. Type 01 at the FISS/DDE Online System Main Menu and then type 12 on the Inquiry Menu for claims.
  3. At the Claims Inquiry screen, type SB6006 in the S/LOC field and press <Enter>. All claims in the SB6006 status and location will be displayed, indicating an ADR has been generated.
  4. At the desired claim, type S to the left of the claim under the SEL field and press <Enter>.
  5. Locate the ADR letter on page 06 of the claim.

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Posted 7/9/2025