FISS Narrative:
Medical records were not received in response to an ADR in the required time frame; therefore, we were unable to determine medical necessity.

Explanation and Suggestion:

  • Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted.
  • Alert your mail staff that the ADRs will be mailed by Palmetto GBA with "ADR Requests Time Sensitive" on the outside of the envelope to assist them in readily identifying the ADRs
  • Be aware of the need to submit medical records within 45 days of the ADR date. The ADR date is in the upper left corner of the ADR request.
  • Gather all information needed for the claim and submit it all at one time
  • Submit medical records as soon as the ADR is received
  • Attach a copy of the ADR request to each individual claim
  • If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records.

IMPORTANT: The fastest and most efficient way to submit your ADR documentation to Palmetto GBA is through eServices

If you choose to mail, be sure to allow extra days to ensure the records are received before the 45th day!

  • Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost
  • Do not mail packages C.O.D.; we cannot accept them
  • Return the medical records to the address on the ADR. Be sure to include the appropriate mail code. This ensures your responses are promptly routed to the Medical Review Department.

Contact Palmetto GBA JM Part A Medicare

Provider Contact Center: 855-696-0705

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