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
- When returning ADR responses for multiple claims, 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.
- Include a completed Medicare Medical Review ADR Response Cover Sheet. Use one ADR Response Cover Sheet for each ADR letter/claim.
- Return your documents using one of the following methods. Do not submit by more than one method as a duplicate response slows down the documentation review process
- Submit your ADR response via the esMD (Electronic Submission of Medical Documentation) mechanism. For more information about esMD, please see the CMS website at www.cms.gov/esmd.
- 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.
- 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 30 days. For claims received prior to March 1, 2015, CMS required 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 receive a status of paid, denied or rejected.
- If you disagree with a denial or payment, you can request a redetermination. Information on requesting a redetermination can be found in Medicare Appeals.
- If the claim was rejected as unprocessable with remittance message MA130, you must submit a new corrected claim
Palmetto GBA has developed several checklists that will assist you with responding to medical record documentation requests.