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Additional Documentation Request (ADR) Process

WHAT IS AN ADR? – When a claim is selected for review or when additional documentation is needed to complete the claim, letter (ADR) is generated requesting documentation and/or medical records be submitted. The response must be submitted within a specified time frame to the requesting contractor identified on the letter for review and payment determination. An ADR may be sent by CGS, Zone Program Integrity Contractors (UPICs), Recovery Audit (RA) contractors, Supplemental Medical Review Contractors (SMRCs), the CERT Contractor, etc.

WHY AN ADR? – Any claim submitted to Medicare contractors may be selected for an additional documentation request (ADR). Claims may be selected when elements on the claim match the parameters of a pre-payment edit. To assist you in determining the types of documentation needed, we have provided you with an online tool which allows you to enter the CGS or ZPIC ADR number. You will receive specific information based on your individual ADR number along with additional resources to make creating your response easier.

WHERE DO YOU FIND THE ADR NUMBER? – CGS places the 3-digit ADR number just below the claim line details. The UPICs place the number at the end of the documentation requirements section of the letter.

An ADR may also be sent for a post-pay review by a Medicare contractor. The information being provided in this section currently pertains to pre-payment ADRs only.

WHAT IS THE DIFFERENCE BETWEEN AN ADR AND AN ADS LETTER? – The terms ADS (Automated Development System) and ADR are sometimes used interchangeably. However, ADR is the appropriate term to cover all requests for additional documentation from Medicare contractors and includes pre- and post-pay. ADS is actually the name of the sub-system used by Medicare contractors.

ABOUT THE ADR LETTER: - When you receive an additional development request (ADR) letter, the Medicare contractor is providing you with a specific list of items billed on the claim and the types of documentation needed to verify that items submitted on your claim meet policy requirements, are coded correctly, and/or are paid based on Medicare guidelines.

HOW TO RESPOND TO THE ADR LETTER: – When responding to the ADR letter, it is important that you fully understand what has been requested and when it must be returned to the contractor. Note: The timeline for your response varies between CGS and the UPICs. You must also package and submit the information correctly. Proper labeling and submission is critical to ensuring your response is processed promptly and accurately. To assist you, CGS has provided a sample letter below which highlights important information you need to know when responding to a CGS request for additional documentation. (Fig 1)

(Fig 1)

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Each letter specifies how long you have to respond. If you do not reply within that time, you may receive a partial or complete denial of your claim.

  1. ALWAYS place this page on TOP of the information you return to the Medicare contractor who requested the documentation. This is very important! At CGS, we use theĀ QR code (item #1 above) to control your response. A coversheet is NOT needed if you are faxing your response.
  2. Review the claim information. This tells you which claim has been selected for review.
  3. Review the specific claim line information which shows what you billed and how you billed it.

(Fig 1)

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  1. This section provides you with the claim that is being reviewed.
  2. The ADS REF number is the ADR number. You can use this 3-digit number to search through ourĀ online tool to provide you with additional ADR information. Simply enter the ADS REF (ADR) number identified on your letter and the system will return additional information to support your response to the ADR letter.
  3. This section details the specific information requested to support our review and payment decisions.

THE CORRECT WAY TO RETURN YOUR DOCUMENTATION:

  1. Remember: You have a set amount of days from the date of the letter to provide your documentation. Refer to your request letter for the specific time frame.
  2. Always return your documentation to the Medicare contractor identified in the ADR. This information will normally be in the return address and/or in the body of the letter. Since different contractors may use very similar-looking letters, pay close attention. Sending a response to the wrong contractor could result in significant problems in getting your claim processed promptly and accurately.
  3. Always place the ADR letter as the cover sheet ON TOP of your documentation. The QR code is often used to help some contractors process your claim information.
  4. Clearly identify the documentation you have returned:
    1. At CGS, it is acceptable (and preferable) to include a separator title sheet for each requested record/document within a response on a claim. For example, if providing physician notes, a page labeled "Physician Notes" is acceptable. If providing a delivery ticket, a page labeled "Delivery Ticket" is acceptable. Remember, this process may be different for other contractors so it is important that you review their requirements carefully.
  5. Be sure to provide all requested documents. If your ADR letter requests six (6) documents, please be sure your response contains all six requested documents.
  6. If you need additional information on the kinds of appropriate documentation needed, you are encouraged to use our online ADS REF (ADR) tool. When you enter the ADS REF (ADR) number located on your letter, you will receive additional information about the type of review your claim is undergoing as well as additional resources specific to your review which may help in determining which documentation requirements must be met.
  7. Make sure your documentation is clear and legible.
  8. Make sure to only send 1 response with your documentation. That response will be used to make the claim decision.
  9. Always send separate responses for each claim and never combine them.
  10. You may return your documentation using a variety of methods. Your options are included in your ADR letter, so refer to the letter for any specifications from the requestor:
    1. U.S. mail
    2. FAX
    3. CD/DVD
    4. EsMD

COMMON MISTAKES YOU SHOULD AVOID:

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