This page contains samples of many of the documents that a provider might need or expect to receive from the RA. Please click on any of the below links to see the sample document. Sample Additional Documentation Request (ADR) Letter Automated Review Audit Notice Letter MD MS-DRG ADR 1 day stay template Update MD ADR 7.27.11 Highmark J12- Part A Demand Letter Highmark J12- Part B Demand Letter NGS J13- Part A Demand Letter NGS J13- Part B Demand Letter NHIC J14 Part A Demand Letter NHIC J14 Part B Demand Letter WPS - Automated Demand Letter WPS - Complex Review Demand Letter Sample Test Claim ADR Letter Sample ADR Letter - J14 (MA, ME, NH, RI, VT) and Home Health and Hospice Review Results Letter for Improper Payments Review Results Letter - No finding Sample of Letterhead
Sample of Envelope Logo Discussion Closed Without Review - Timeframe Exceeded
DCS Discussion Period Request Form 2012
Close Discussion Period due to Appeal Decision Upheld Letter Decision Overturned Letter HOW TO INTERPRET THE REMITTANCE ADVICE Highmark J12 - Electronic Remittance NGS J13 - Remittance Advice NHIC J14 - Remittance Advice - Part B Understanding Remittance Advice (CMS website)