Additional Documentation Request

Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.  This is done by our Medicare medical review contactors through an Additional Documentation Request (ADR).  Medicare Fee-for-Service (FFS) medical reviews are conducted by Medicare Administrative Contractors (MACs), the Supplemental Medical Review Contractor (SMRC), Recovery Audit Contractors (RACs), Unified Program Integrity Contractors (UPICs), and others.

What is an ADR?

An additional documentation request (ADR) is generated when documentation is necessary to support a Medicare claim. This request is for medical record documentation to support payment of an item(s) or service(s) reported on the claim to ensure compliance with Medicare's coverage, coding, payment and billing policies.

The ADR is sent to a provider's practice address on file with Medicare. To ensure you are receiving your ADR to the correct address, be sure to update your 'Medical Review Correspondence Address' in the Provider Enrollment, Chain, and Ownership System (PECOS) system.

How do providers/suppliers respond to an ADR?

When preparing your documentation, it is best practice to attach a copy of the ADR letter as the first page to ensure the documentation is matched to the appropriate patient and claim.

Providers/Suppliers should submit the necessary documentation to support the services for the billing period being reviewed. This may include documentation that is prior to the review period.

Documentation may be received by your MAC either via US Mail, esMD, your MAC designated provider portal, Fax, or on compact disc (CD), digital video disc (DVD), or universal serial bus (USB).

Is there a specific timeframe to respond?

Yes, depending on the type of review (pre-payment or post-payment) and who is conducting the medical record review, there are specific timeframes for provider/supplier response.

Prepayment Review by MACs

• As outlined in 42 CFR § 405.903 Prepayment review, a provider or supplier will be provided 45 calendar days to submit additional documentation in response to a contractor's request.

Prepayment Review by UPICs

• As outlined in 42 CFR § 405.903 Prepayment review, a provider or supplier will be provided 30 calendar days to submit additional documentation in response to a UPIC's request for additional documentation.

Post-payment Review by MACs, SMRC, and RACs

• As outlined in 42 CFR § 405.929 Post-payment review, a provider or supplier will be provided 45 calendar days to submit additional documentation in response to a contractor's request.

Post-payment Review by UPICs

• As outlined in 42 CFR § 405.929 Post-payment review, A provider or supplier will be provided 30 calendar days to submit additional documentation in response to a UPIC's request for additional documentation.

What if I cannot meet the specific timeframe for the request?

For MACs, SMRC, and RACs reviews, the contractor may accept documentation received after 45-calendar days for good cause. Good cause means situations such as natural disasters, interruptions in business practices, or other extenuating circumstances that the contractor deems good cause in accepting the documentation.

For UPIC reviews, the contractor may accept documentation received after the 30 calendar days for good cause. Good cause means situations such as natural disasters, interruptions in business practices, or other extenuating circumstances that the UPIC deems good cause in accepting the documentation.

We encourage providers and suppliers to work with your designated MAC if additional time is needed to respond to the ADR.

What if I do not respond to the ADR?

As outlined in 42 CFR § 405.930 Failure to respond to additional documentation request, if a contractor gives a provider or supplier notice and time to respond to an additional documentation request and the provider or supplier does not provide the additional documentation in a timely manner, the contractor has authority to deny the claim.