Audit and Compliance



Review Contractors issue an estimated 2 million requests each year for medical documentation, according to the Centers for Medicare and Medicaid (CMS). Most often, those requests are fulfilled through manual processes that include printing documentation and submitting it via traditional mail or fax. The fulfillment process can be tedious, cumbersome and leave risk for human error.

Medical documentation is the central component of the claims review process-the key driver that enables proper payment adjustments and increased reimbursement for providers. Ensuring efficiency, accuracy and security throughout this process is absolutely critical to success.

A project from CMS-the Electronic Submission of Medical Documentation (esMD) to Providers, Review Contractors, and Health Information Handlers (HIHs)-offers providers new options to respond to requests for medical documentation and ultimately expedite the claims review process. The esMD system provides an electronic option for providers and HIHs to respond to Additional Documentation Request (ADR) letters and allows review contractors to electronically receive those responses.

Using the esMD system is not mandatory for providers, but there are significant benefits to opting to use this system.

  • Reduce Administration Costs. Providers can benefit from eliminating paper waste and investing time in burning files to disks. With electronic submissions, medical documentation is directly sent to contractors without this additional step.
  • Enhanced Efficiency and Response Rates. The esMD system facilitates a faster submission process, which enables a faster response rate and, in turn, a faster payment decision or appeal process. In fact, according to CMS, providers have reported the payment turnaround time is six days when using the esMD system as opposed to three weeks when using the paper process.
  • Security. The esMD system complies with security regulations set forth by the eHealth Exchange, formerly known as the Nationwide Health Information Network (NHIN). These security regulations include standards, protocols, legal agreements, and specifications identified by a consortium of health information organizations as necessary for secure and private exchange of health information over the internet.

The esMD system initially launched in September 2011 and, since then, has consistently expanded to include new features and functionality. Today, the esMD system can be used for the following types of documentation:

  • To Review Contractors
    • Responses to Documentation Request Letters in PDF
    • Power Mobility Device (PMD) Prior Authorization Requests in PDF
    • 1st level Appeal Requests in PDF
    • Advance Determination of Medicare Coverage
    • Prior authorization request for ambulance in PDF
    • Prior authorization request for HBO in PDF
    • Prior authorization request in X12 278
    • Structured Orders, Progress Notes
    • Structured esMD Phase 2 Registration
  • To Providers
    • Power Mobility Device (PMD) Prior Authorization Responses
    • Prior authorization responses
    • Structured Outbound Documentation Requests (coming soon)
    • Review Results Letters (coming soon)
    • Demand Letters (coming soon)

Soon, the scope of the esMD project will debut new functionality to further streamline the claims review process through the electronic submission and receipt of information. These new features include:

  • emDR: Enabling providers to electronically receive the Initiating Request Letter.
  • Review Results: Enabling providers to electronically receive the initial determination letter.

To learn more about how the system works visit the CMS website.

With the right support and resources, getting started with esMD is easy. In order to use the system, providers must:

  • Confirm their claim review contractors accept esMD transactions.
  • Obtain access to an esMD gateway.

Providers can gain access to the esMD gateway in one of two ways. Some larger hospitals or health systems may opt to build their own gateway, given the right resources. While this is possible it's not a commonly used option. Most providers choose to work with an HIH to support ease in adopting and implementing the esMD system.

For a list of HIHs that provide esMD gateway access, click here.