Responding to a Home Health Additional Documentation Request (ADR)

The following list is a recommendation for what to include when responding to a Home Health Additional Documentation Request (ADR):

Plan of Care and Certification

  • Plan of care and certification be signed and dated prior to billing the end of episode claim
  • Plan of care must cover entire billing period
  • Physician orders not included on the plan of care must be signed and dated prior to billing the final claim to Medicare
  • Physician signature needs to be present, legible and dated, include signature log or attestation of signature is illegible
  • If alternative signatures are used, submit documentation as outlined in Centers for Medicare & Medicaid Services (CMS) Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.2.8
  • Initial plan of care/certification needs to be included on all responses

Face to Face Encounter

  • Must be completed no earlier than 90 days prior to or up to 30 days after the start of care
  • Face-to-face documentation must  include clinical findings to support the need for skilled services
  • Face-to-face documentation must  support homebound status
  • Face to face documentation should be submitted for all episodes
  • If the face to face was performed by someone other than the certifying physician, the date of the encounter must be recorded and signed by the certifying physician or the encounter needs to be co-signed by the certifying physician 

Documentation of Services Rendered

  • Adequate documentation is needed to determine medical necessity of all services billed and to support the Health Insurance Prospective Payment System (HIPPS) code (or level of payment) billed
  • If the medical review for this claim is revenue code specific, you may choose to send notes for the discipline in question, a summary of services rendered or complete field 15 of form CMS 486 or equivalent form for other disciplines billed; however, all services billed will be reviewed
  • When intermittency is in question, documentation must include in/out time for nurse and aide visits and the projected endpoint to daily skilled nurse visits. An endpoint statement must include when daily skilled nurse visits are projected to decrease to less than daily.
  • Documentation for all PRN visits, including dates, reason for the PRN visits, outcome of visits and orders for services must be included
  • Include any other pertinent documentation that may be needed to establish medical necessity (e.g., date of hospitalization, medication changes, laboratory values, physician contacts/visits, etc.)
  • Submit documentation denoting treatment week, when different from calendar week
  • Itemized supply list if billed:
    • Include the quantity and cost of each item
    • Include physician orders signed and dated prior to billing the end of episode claim to cover all supplies billed
  • Please send a manifest with medical records submitted and send the medical records in secure packaging to ensure the security of medical records
  • If responding to multiple requests in a single envelope, ensure each response is clearly separated. If responding to more than one date of service on the same beneficiary, send a response for each request separately. Include a manifest or list identifying each ADR response sent.
  • Attach a copy of the original ADR with the original ADR barcoded letter to each individual ADR response
  • Use one staple or elastic band per record to attach the documentation and ADR together. Do not use paper clips as they can become dislodged
  • Do not punch holes in medical records, as this may obscure valuable information
  • Return the medical records to the appropriate address listed below or on the ADR

For Postal Delivery Use:

Medicare Part A Medical Review
Mail Code: AG-230
P.O. Box 100238
Columbia, SC 29202-3238

Courier Service, Use:

Medicare Part A Medical Review
Mail Code: AG-230
BLDG 1
2300 Springdale Drive
Camden, South Carolina, 29020-1728

  • Do not include any correspondence other than ADR responses to the medical review department in your envelope
  • If billing corrections are needed, submit a hardcopy UB-uniform billing (latest version from CMS), with a XX7 bill type along with your medical records
  • Unfortunately, we are not able to accept packages on a C.O.D. basis. Please make sure that you have sent packages with the shipping prepaid.
  • If you send a CD or DVD for medical review or appeal documentation, please send the entire document (including documents with multiple pages) in a PDF or TIFF format
    • Preferred File Format: PDF or TIFF
    • Do not send an executable file (.exe) or include an .exe program with the PDF or TIFF file
    • SecureZip: be sure the file is zipped using the FIPS 140 encryption algorithm
    • Spreadsheets in excel converted to pdf
    • Email Passwords to DISKINFO@Palmettogba.com or CamdenDC.Inquiry@palmettogba.com 
    • Do not password protect files on Adobe Security feature (separate from password protect on disk), unless you provide the password (locking will prevent us from being able to save or print the file to prep for upload into Iflow)
    • Please don't create a PDF or TIFF file of each page. One PDF or TIFF file per record is acceptable
  • No password is required; however, if you do use a password, please include the tracking number of the documents/disk to ensure we are able to link the CD with the password
  • Records may be faxed to 803-699-2436 (JM MR HHH ADR only).
  • Records may be sent via esMD (Electronic Submission of Medical Documentation System)
  • Providers may also use eServices to submit their responses
  • The Palmetto GBA Medical Review Department developed a Responding to a Home Health Additional Documentation Request (ADR) checklist. Please complete this checklist and include it when responding to an ADR. To access this checklist, select the PDF document below.

Contact Palmetto GBA JM Part HHH Medicare

Email HHH

Contact a specific JM HHH department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 


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