If you receive a Medical Review Additional Documentation Request (ADR) for one or more claims that you have submitted to Medicare for payment, it is important that you comply with the following instructions.
- Provide the documents listed on the ADR and any related physician’s orders. Make sure the physician's signature is legible or include an attestation of signature.
- Include a copy of the ADR with your documents
- Upload your ADR response through our Online Provider Services (OPS) free, self-service portal located on the Palmetto GBA website. OPS lets you upload your ADR response electronically, eliminating the need to fax or mail documents and packages. To participate, you must have an EDI agreement on file with Medicare. When you upload a document, you will receive a message when the form is submitted and another message with the Document Control Number (DCN) when the form has started processing. You can use the DCN to look up form processing status and view your submitted forms.
- When mailing multiple claim ADR responses, be sure to pair each ADR letter with the corresponding documentation. Pairing these documents ensures the documentation for each request letter is correct for each date of service requested.
- Return your documents to the Palmetto GBA medical review mailing address or fax number located in the body of the ADR letter
- Return your ADR response to Palmetto GBA within 30 days of the date on the ADR letter. The claim will automatically deny by the 45th day if a response has not been received. There is no guarantee that any responses received between day 30 and 45 will be processed prior to the claim being denied.
- Once ADR responses are received, CMS requires Palmetto GBA to complete medical review of the documentation within 60 days. Do not resubmit ADR responses to Palmetto GBA.
- Do not submit replacement/duplicate claims for the ones pending in medical review. The submission of replacement/duplicate claims will result in claim denial, rejection or recoupment and will prolong the medical review process. When the claim is finalized, the claim will have paid in full or part, or denied. If you disagree with the decision, you can request a redetermination within 120 days of the determination (date on the remittance advice).
Palmetto GBA has developed several checklists that will assist you with responding to medical record documentation requests.