Print the complete Portal User Manual 

Providers can use the WPS Government Health Administrators Portal to submit medical documentation for pre- and post-payment reviews. These are the reviews initiated by the Medical Review department. 

Please note, documentation for PWK or in response to Fiscal Intermediary Standard System (FISS) reason code U5601, should not be uploaded via the portal.

Providers can also use the portal to search for documentation previously submitted for a pre- or post-payment review.

You can access the Medical Documentation function by selecting the Medical Documentation link under the Claims heading in the left navigation menu. (If you do not see the Medical Documentation link, click the arrow next to the Claims heading to open the Claims menu.)

NOTE: Providers who disagree with a claim determination and want to submit supporting documentation should not follow the instruction in this section. See Appeal Submission for information about requesting a redetermination.

Determining the Type of Medical Review

Before uploading your documentation, you need to determine if Medicare is conducting a prepayment review or a post-payment review. To avoid processing delays or possible claim denials, you must select the correct type of review when uploading your documentation.

You will find the information in the letter Medicare sent you requesting the documentation.

• If your letter indicates it is an Additional Documentation Request (ADR), Medicare is conducting a prepayment review.
• If your letter indicates Medicare is conducting a Post Pay Review and contains a list of the selected claims, Medicare is conducting a post-payment review.

Documentation Requirements in the Portal

The portal accepts the following file types:

• .docx
• .xlsx
• .pdf
• .jpg
• .jpeg
• .gif
• .tif
• .tiff
• .zip

Additional documentation tips:

• You can only upload one file per claim. The file size cannot be larger than 100 MB. 
• If you have multiple files to provide, all files must be included in a single .zip file.
• If you submit a .zip file, it shall contain no more than 60 files, and all files within the .zip file must be in one of the formats listed above.
• We cannot accept documents that have password protection, macros, or external links. 

Uploading Documentation for a Prepayment Medical Review (ADR Response)

There are two methods for uploading documentation for a prepayment review. The more accurate method uses the Claim Inquiry function. However, this method is only available when the claims processing system is online. If you need to respond to an ADR letter when the claims processing system is offline, portal users can upload documentation using the prepayment review tab.

Uploading Documentation for a Prepayment Medical Review Using Claim Inquiry

The most accurate way to submit documentation in response to an ADR letter is to begin by locating the claim using the Claim Inquiry function. You can access the Claim Inquiry function by selecting the link in the left navigation menu or by using the link located on the Medical Documentation page:

NOTE: This method is only available when the claims processing system is online. If you need to respond to an ADR letter when the claims processing system is offline, see the next section for instructions on responding using the prepayment review tab.

Step 1: Once you locate the claim using the Claim Inquiry function, you can start the upload by clicking on either the MR button or the Add Documentation button. You can find these buttons in the following places:

• On the Claim Results page after searching for the claim using the Claim Inquiry function (NOTE: The MR button will be dark blue if it is available. If the button is light blue, you cannot upload documentation for that claim.)
  
   
• In the Claim Actions area after selecting the claim in the Claim Results (NOTE: The Add Documentation button will be dark blue if it is available. If the button is light blue, you cannot upload documentation for that claim.)
  

Step 2: After clicking the MR/Add Documentation button, a pop-up box will open allowing you to upload your documentation. Click the Choose File button to select a file from your computer to upload. After selecting the file to upload, click the Review button to review your information for accuracy and completeness.

 
Step 3: Choose the Submit button to upload the documentation, the Edit button to make changes, or the Cancel button to end the process.

Step 4: After uploading your documentation, you will receive a confirmation message containing a confirmation number. Select the Print button to print the page or the Close button to return to the claim detail page.

Uploading Documentation Using the Prepayment Review Tab

If you are unable or choose not to use the Claim Inquiry function to locate your claim before uploading documentation, you can use the Prepayment Review tab. You will need to supply additional information to use the Prepayment Review tab to upload documentation.

Step 1: Access the Medical Documentation function by clicking the link in the left navigation menu, then click the Prepayment Review tab.

Step 2: Enter the following information in the available fields:

• Service Location (NPI)
• Provider Number (PTAN)
• Patient’s Medicare Number
• Claim Number (ICN/DCN)
• Date of Service

Be sure to verify the information you entered is accurate to avoid unnecessary delays or denials.

Step 3: Click the Choose File button and select the file you want to upload from your computer. 

Step 4: Confirm the information you entered is accurate and click the Submit button to upload the documentation. Once you successfully upload the documentation, you will see a confirmation message with a confirmation number. You can print the information for your record or click OK to return to the previous screen. 

Uploading Documentation Using the Post-Payment Review Tab

Unlike prepayment reviews, which apply to a single, specific claim, post-payment reviews (probes) may involve multiple claims. For this reason, you cannot use the Claim Inquiry function to start submitting documentation for a post-payment review.

Step 1: Access the Medical Documentation function by clicking the link in the left navigation menu, then click the Post-payment Review tab.

Step 2: Enter the following information in the available fields:

• Service Location (NPI)
• Provider Number (PTAN)
• Probe Number
• Patient’s Medicare Number
• Claim Number (ICN/DCN)
• Date of Service

Be sure to verify the information you entered is accurate to avoid unnecessary delays or denials.

Step 3: Click the Choose File button and select the file you want to upload from your computer. 

Step 4: After confirming everything is correct, click the appropriate button depending on if there are additional claims included in the probe.

• If you have additional documentation to submit for the same probe (for different claim numbers), click Save and Submit Another File.
• If you are done submitting documentation for the probe, click Submit and Finish.

Once you successfully upload the documentation for the probe, you will see a confirmation message with a confirmation number. You can print the information for your record or click OK to return to the previous screen. 

NOTE: You can submit documentation for up to 400 claims in one submission. If you have more than 400 claims included in a single probe, submit the documentation for the first 400 claims and receive your confirmation number. You can then repeat the same steps with the remaining claims in the probe. Please be sure to enter the same NPI, PTAN, and probe number. 

Searching for Medical Documentation in the Portal

You can search for medical documentation submitted by your service location. This may be helpful several reasons, including if you are unsure if your group has already responded to a medical documentation request.

To search for documentation, navigate to the Medical Documentation page and click the Search Documentation button near the top of the page.

On the Medical Documentation Search page, you can view medical documentation submitted for your service locations (NPIs) and for Medical Review findings. By default, the results will be listed in the order we received them with the most recent listed first. You can click on the column headings to sort by each of the columns. 

You can search and sort the documentation in the following ways:

• Use the Quick Filter and enter the Claim Number (ICN/DCN)
• Use the Quick Filter and enter the Patient Medicare Number. You will need to search using the MBI if you submitted the documentation with the MBI or the HICN if you submitted the documentation with the HICN.
• Use the “My Submissions Only” button to show only documents you have submitted.
• Use the “Show entries” dropdown to increase the results per page.
• Sort by using the arrows next to the column headings.
• Filter using the “Filter” box. (You can search for any information appearing in the table, such as Confirmation Number or Submitted Date.)

Status Codes:

• Received – The attachment has been submitted and is waiting for virus scanning.
• Pending – The Medical Documentation has been received. Medical Documentation submissions will remain in Pending status. The Medical Review Targeted Probe and Educate (TPE) findings will be returned on a new tracking number.
• Completed – The Medical Review findings are available to view.
• Not Accepted – The file was invalid or corrupt. Review the accepted file types and resubmit.

NOTE: Documentation remains in pending status even after our Medical Review staff has reviewed it. For regular claim development responses, you will see the decision on your remittance advice when the claim finalizes. To find the TPE decision, filter on Completed. You will need to search for decisions rendered after you submitted the documentation. A decision is normally rendered within 30 days after documentation is submitted. The response will be from OBUSER in the Submitted By column. You will need to make sure the My Submissions Only box is not checked when searching for a decision

Once you locate the record you wish to view, click the Confirmation Number link to view the details. 

You may also be able to view the documentation submitted by clicking the link under File Name. (This option may not be available for some claims, especially those that are older.)