Submitting Medical Records to Medicare via esMD: Step-by-Step ADR Submission Guide

Introduction

For years, providers responded to Medicare Additional Documentation Requests (ADRs) by mailing paper records, faxing hundreds of pages, or burning CDs. Those methods are slow, costly, and hard to track. CMS created the Electronic Submission of Medical Documentation system, known as esMD, to offer a faster and more secure alternative.

Through esMD, providers can send ADR responses and other documentation electronically to Medicare review contractors, and they can receive electronic ADR letters and review results. CMS reports that providers have experienced faster turnaround with esMD than with paper. esMD is voluntary, but for organizations that handle many ADRs, it can save time, reduce costs, and improve tracking.

This step-by-step guide explains what esMD is, who accepts it, how Health Information Handlers work, how to register for electronic ADRs, how to prepare and submit documentation, how to confirm receipt, how timeliness works, and how to avoid common errors. It is educational and does not replace professional advice. Technical details can change, so always follow current CMS esMD guidance and your Health Information Handler's instructions.

What Is esMD?

CMS describes esMD as a secure electronic channel for exchanging supporting documentation between Medicare fee-for-service providers and review contractors. CMS explains that, before esMD, review contractors sent paper ADRs and providers responded by mail or fax. CMS's current esMD materials describe the system as using custom implementations of HL7 FHIR healthcare data standard application programming interfaces (APIs).

What Providers Can Send Through esMD

According to CMS, providers can use esMD to send:

• Responses to ADRs.

• First and second level appeal requests.

• Recovery Audit Contractor (RAC) and DME discussion requests.

• Advance Determination of Medicare Coverage (ADMC) requests.

• Unsolicited claim-related documentation (paperwork, or PWK).

• Prior authorization requests with supporting documentation.

What Providers Can Receive Through esMD

CMS explains that providers can receive:

• Electronic Medical Documentation Requests (eMDR), which are electronic ADR letters.

• Prior authorization responses and decision letters.

• Review results letters.

Is esMD Required?

No. CMS has consistently described esMD participation as voluntary. Providers can continue to use other accepted submission methods, such as mail, fax, CD or DVD, and contractor portals.

Why Use esMD?

CMS identifies several benefits:

• Faster turnaround. CMS reports that providers have experienced about 6 days to payment with esMD compared with about 3 weeks for the paper process.

• Lower labor costs, because staff no longer need to print, mail, fax, or burn CDs.

• Lower hard costs, such as shipping and handling.

Other practical advantages include electronic tracking of submissions and, for providers registered for eMDR, faster receipt of ADR letters. CMS's Program Integrity Manual also states that for esMD submissions, the esMD cloud receipt date controls for timeliness, which can provide clarity about when a response was received.

Which Review Contractors Accept esMD?

CMS's esMD materials list review contractors that accept esMD submissions, including:

• Medicare Administrative Contractors (A/B MACs) across all jurisdictions, including Noridian, CGS, National Government Services, First Coast Service Options, Palmetto GBA, Wisconsin Physicians Service, and Novitas Solutions.

• DME MACs, including Noridian and CGS.

• The Supplemental Medical Review Contractor (Noridian).

• Recovery Audit Contractors, including Performant and Cotiviti.

• Unified Program Integrity Contractors, including Qlarant, Safeguard Services, and CoventBridge.

• The CERT contractor.

• Qualified Independent Contractors (QICs) for reconsiderations.

• Certain Quality Improvement Organizations.

CMS maintains an updated list on its esMD website. Before submitting, confirm that the contractor that sent your ADR accepts esMD.

How Health Information Handlers Work

What Is an HIH?

Providers do not usually connect to esMD directly. Instead, they use a Health Information Handler (HIH). CMS describes HIHs as organizations that develop APIs to facilitate document exchange between providers and CMS. Types of HIHs include health information exchanges, release of information vendors, electronic health record vendors, claim clearinghouses, and health internet service providers.

Two Ways to Access esMD

CMS explains that providers can submit through esMD either by becoming an HIH themselves, which requires building a connection to esMD, or by using the services of a CMS-certified HIH. Most providers use an existing HIH.

Costs

CMS notes that HIHs are not funded by CMS. HIHs set their own pricing and service terms, so providers should compare options.

Certified HIHs

CMS publishes a list of CMS-certified HIHs on its esMD website. Providers should select an HIH from the current CMS list and evaluate it based on integration with their systems, cost, support, and features.

Step-by-Step: Setting Up esMD

Step 1: Confirm Your Contractors Accept esMD

Identify the contractors that send you ADRs, such as your MAC, DME MAC, RAC, and others, and confirm they accept esMD using CMS's current list.

Step 2: Choose a Health Information Handler

Select a CMS-certified HIH. Consider:

• Whether it integrates with your EHR, release of information, or billing systems.

• Whether it supports the lines of business you need, such as ADR responses, appeals, and prior authorization.

• Whether it supports eMDR.

• Pricing, support, training, and reporting tools.

Step 3: Sign the Necessary Agreements

Because medical records contain protected health information, providers need appropriate agreements with their HIH, including a HIPAA business associate agreement. CMS's eMDR guidance notes that providers must have active security and privacy agreements with their HIH.

Step 4: Register for eMDR (Optional but Recommended)

eMDR allows you to receive ADR letters electronically. CMS's MLN Matters article MM11003 describes the registration process:

• An authorized person updates the provider's record in the National Plan and Provider Enumeration System (NPPES) by adding endpoint information in the Health Information Exchange section, affiliated with the HIH, with the use designated for CMS esMD eMDR.

• After NPPES reflects the update, the HIH sends an eMDR enrollment request to esMD and completes additional processing steps.

• Registration is not effective until all steps are completed without discrepancies.

Important points from CMS:

• A provider can have only one active HIH agreement at a time for all supported lines of business.

• eMDR enrollment applies to all of the provider's PTANs.

• The first 500 ADRs are sent both electronically and by mail as a transition step.

• The provider is responsible for keeping NPPES updated with current HIH details.

• MAC portal and Direct Data Entry enrollments are separate from eMDR.

• Group practices and hospitals that want electronic ADRs must register their own group or hospital NPI.

• Some contractors, including PERM contractors, QIOs, and UPICs, do not send eMDRs.

Step 5: Train Staff

Train ADR coordinators and health information management staff on how to receive eMDRs, prepare submissions, use the HIH's tools, and track confirmations.

Step-by-Step: Submitting an ADR Response Through esMD

Step 1: Read the ADR and Gather the Required Information

Identify the contractor, claim identifiers, beneficiary, dates of service, documents requested, and due date. Note any reference numbers or barcode information the contractor requires.

Step 2: Prepare the Documentation

Assemble the response just as you would for any ADR:

• Place the ADR letter or required cover information first, following contractor instructions.

• Include a cover letter and index if helpful.

• Organize records logically.

• Include signature logs or attestations when appropriate.

• Make sure documents are legible and complete.

Convert documents to the format your HIH requires, commonly PDF, and check file sizes and naming conventions.

Step 3: Enter the Required Metadata

Your HIH will ask for information that esMD uses to route the submission correctly. This typically includes:

• The review contractor receiving the submission.

• The type of submission, such as an ADR response. CMS's esMD implementation guide uses content type codes to identify the line of business, and CMS updates these codes periodically. For example, CMS introduced a new content type code in its October 2026 release to support ADR responses for the WISeR program.

• Claim and ADR identifiers.

• Provider identifiers, such as NPI.

• Beneficiary identifiers.

Errors in metadata are a common reason submissions are rejected or misrouted, so check this information carefully.

Step 4: Handle Large Submissions

Large ADR responses may need to be split into smaller parts. CMS's esMD implementation guide includes a split number field used when an HIH divides a large payload into smaller parts. Your HIH will explain how to handle large files. Make sure each part is labeled correctly so the contractor can reassemble the complete response.

Step 5: Submit Before the Deadline

Submit through your HIH well before the due date. CMS's Program Integrity Manual states that for esMD submissions, the esMD cloud receipt date controls. CMS's manual also requires contractors to pull esMD files at least every four business hours, including a pull between 6 and 7 p.m. Eastern Time. Even so, submitting early leaves time to fix problems.

Step 6: Track Confirmations and Notifications

esMD and your HIH provide status information about your submission. Monitor your HIH's dashboard or notifications to confirm that:

• The submission was accepted by esMD.

• The submission was delivered to the review contractor.

• No errors were reported.

If an error is reported, such as invalid metadata or a submission that the contractor identifies as unsolicited or unmatched, correct and resubmit promptly.

Step 7: Keep Records

Save the submission confirmation, transaction identifiers, and a copy of everything submitted. Record the submission date and confirmation in your ADR log.

Step 8: Monitor Results

Watch for review results letters, which may be delivered electronically through esMD if you are registered, and for claim status updates and remittance advice.

Common esMD Errors and How to Avoid Them

• Sending to a contractor that is not the one that issued the ADR. Double-check the contractor before submitting.

• Incorrect or missing claim identifiers. Copy identifiers directly from the ADR letter.

• Wrong submission type. Make sure the submission is identified as an ADR response, not unsolicited documentation or an appeal.

• Mismatched provider or beneficiary information. Verify NPI and beneficiary identifiers.

• Illegible or incomplete scans. Review files before submitting.

• Large files not split correctly. Follow your HIH's instructions for large submissions.

• Submitting at the last minute. Leave time to correct errors.

• Not checking confirmations. A submission is not complete until you confirm delivery.

• Outdated NPPES information for eMDR. Keep HIH details current.

esMD for Appeals and Prior Authorization

Because esMD also supports first and second level appeals and prior authorization requests, providers can use the same HIH relationship for other documentation exchanges. CMS's esMD materials list QICs among the contractors that accept esMD, which allows reconsideration requests to be submitted electronically. Using one channel for ADR responses, appeals, and prior authorization can simplify workflows.

Choosing Between esMD and Other Submission Methods

esMD is one of several accepted submission methods. CMS's guidance lists mail, esMD, the MAC's provider portal, fax, and CD, DVD, or USB as options for submitting documentation to MACs. Each has advantages:

• esMD works across many review contractors, including MACs, RACs, the SMRC, UPICs, CERT, and QICs, and offers electronic tracking. It requires an HIH relationship, which may involve costs.

• MAC portals are often free and allow providers to upload documentation and view ADRs, but they generally work only with that MAC.

• Fax is widely available but can produce poor-quality images for long records and offers limited confirmation.

• Mail and physical media are slow and require tracking to prove timely delivery.

Many organizations use esMD as their primary method and keep a MAC portal or another method as a backup.

Security and Privacy Considerations

Medical records submitted through esMD contain protected health information. Providers should:

• Execute a business associate agreement with their HIH.

• Confirm the HIH's security controls and compliance with HIPAA requirements.

• Limit esMD access to authorized staff.

• Use strong authentication for HIH portals.

• Send only the documentation needed to respond to the request.

• Keep audit trails of who prepared and submitted each response.

CMS's eMDR guidance explains that because eMDRs may contain protected health information, providers must consent to electronic delivery and maintain active security and privacy agreements with their HIH.

Keeping Up With esMD Changes

CMS updates esMD regularly through technical releases that may add new submission types, content type codes, or features. For example, CMS's esMD technical release documents for 2025 and 2026 describe changes such as new content type codes for specific lines of business. HIHs implement these changes, but providers should:

• Ask their HIH to notify them of changes that affect workflows.

• Review CMS's esMD website periodically.

• Update internal procedures and training when changes occur.

• Confirm that new programs, such as prior authorization or new review demonstrations, are supported by their HIH.

Building esMD Into Your ADR Process

• Designate a staff member responsible for esMD submissions and monitoring.

• Integrate eMDR notifications into your ADR log so new requests are captured immediately.

• Create standard templates for cover letters and indexes in PDF format.

• Establish naming conventions for files.

• Use a second reviewer to check metadata and documents before submission.

• Review HIH reports regularly for errors and delivery confirmations.

• Keep a backup submission method, such as the MAC portal, in case of technical problems.

• Update procedures when CMS or your HIH announces technical changes.

A Hypothetical Example

A hospital that receives several hundred ADRs each year registers for eMDR through its release of information vendor, which is a CMS-certified HIH. After updating NPPES and completing registration, the hospital begins receiving electronic ADR letters along with paper copies during the transition period.

When a new RAC ADR arrives electronically, the hospital's ADR coordinator logs it the same day. The health information management team assembles the records into a single PDF with the ADR letter first, an index, and a signature log. The coordinator enters the RAC as the recipient, selects the ADR response submission type, and copies the claim identifiers directly from the eMDR. Because the file is large, the HIH splits it into two parts.

The coordinator submits on day 20 and checks the HIH dashboard the next morning, confirming that esMD accepted the submission and that it was delivered to the RAC. The confirmation is saved in the ADR log. Several weeks later, the review results letter arrives electronically.

esMD Readiness Checklist

• Confirm which of your review contractors accept esMD.

• Select a CMS-certified HIH and sign a business associate agreement.

• Decide whether to register for eMDR and complete NPPES updates.

• Designate esMD users and backups.

• Create PDF templates for cover letters and indexes.

• Establish file naming conventions and size handling procedures.

• Set up a process to check confirmations after every submission.

• Record esMD transaction identifiers in your ADR log.

• Keep a backup submission method available.

• Review CMS esMD updates and HIH notices regularly.

• Train staff on all of the above and refresh training periodically.

Frequently Asked Questions

Is esMD mandatory?

No. esMD is voluntary. Providers can continue to use other accepted submission methods.

Do I need an HIH to use esMD?

Most providers use a CMS-certified HIH. Alternatively, an organization can become an HIH itself, which requires building a technical connection to esMD.

Does CMS pay for HIH services?

No. CMS states that HIHs are not funded by CMS. HIHs set their own pricing.

How is timeliness determined for esMD submissions?

CMS's Program Integrity Manual states that the esMD cloud receipt date controls.

Can I receive ADR letters electronically?

Yes. Providers can register for eMDR through their HIH and NPPES to receive ADR letters electronically. During the transition, the first 500 ADRs are also sent by mail.

Do all contractors send eMDRs?

No. CMS notes that PERM contractors, QIOs, and UPICs do not send eMDRs, although many contractors accept esMD submissions.

Can I submit appeals through esMD?

Yes. CMS states that providers can send first and second level appeal requests through esMD, and QICs are listed among the contractors that accept esMD.

What happens if my esMD submission is rejected?

Your HIH should notify you of errors. Correct the problem, such as invalid identifiers or metadata, and resubmit promptly so the response is received before the due date.

How long does it take to set up esMD?

It depends on your HIH and internal systems. Selecting an HIH, signing agreements, and training staff can take weeks, and eMDR registration requires additional steps. Set up esMD before you need it rather than in the middle of an ADR deadline.

Can different departments use different HIHs?

For eMDR, CMS notes that a provider can have only one active HIH agreement at a time for all supported lines of business, so coordinate HIH selection across departments.

Conclusion

esMD offers Medicare providers a faster, more secure, and more trackable way to respond to ADRs and exchange other documentation with review contractors. By confirming that contractors accept esMD, choosing a CMS-certified Health Information Handler, putting the right agreements in place, registering for eMDR, preparing well-organized documentation, entering accurate metadata, submitting early, confirming delivery, and keeping records, providers can reduce the risk of missed deadlines and lost documents while saving time and money.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps providers evaluate and implement esMD, select and onboard Health Information Handlers, register for eMDR, build electronic ADR workflows, prepare organized submissions, and monitor confirmations and results. If you would like help submitting ADR responses through esMD, please get in touch with us. We will be happy to help you with this topic.

References

• Centers for Medicare & Medicaid Services. Electronic Submission of Medical Documentation (esMD). https://www.cms.gov/data-research/computer-data-systems/esmd

• Centers for Medicare & Medicaid Services. esMD Information for Providers. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Information_for_Providers.html

• Centers for Medicare & Medicaid Services. Introducing esMD to Providers, Review Contractors, and Health Information Handlers (March 2026). https://www.cms.gov/files/document/introducing-esmd-providers-review-contractors-health-information-handlers.pdf

• Centers for Medicare & Medicaid Services. esMD FHIR Implementation Guide. https://esmdguide-fhir.cms.hhs.gov/index.html

• Centers for Medicare & Medicaid Services. esMD HIH Technical Release Changes, AR2026.10.0 Release. https://www.cms.gov/files/document/esmd-hih-trc.pdf

• Centers for Medicare & Medicaid Services. MLN Matters MM11003, Electronic Medical Documentation Requests (eMDR) Registration (Revised March 20, 2024). https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/mm11003.pdf

• Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 3, Verifying Potential Errors and Taking Corrective Actions. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf

• Centers for Medicare & Medicaid Services. Additional Documentation Request. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-education/additional-documentation-request

• Centers for Medicare & Medicaid Services. Review Contractor OID Table (Updated May 21, 2026). https://www.cms.gov/files/document/rc-oid-table.pdf

• Centers for Medicare & Medicaid Services. National Plan and Provider Enumeration System (NPPES). https://nppes.cms.hhs.gov/

• U.S. Department of Health and Human Services. HIPAA Business Associates. https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/business-associates/index.html