How do you answer an ADR or prepayment review request on time?

What is an ADR and how long do you have to answer?

An ADR, or additional documentation request, is a Medicare contractor's letter asking you to send the records that support a claim. You have 45 calendar days to answer a request from a MAC, RAC, SMRC or CERT, and 30 calendar days to answer a UPIC.

The Program Integrity Manual cites 42 CFR 405.903 for prepayment requests and 42 CFR 405.929 for post-payment requests, and it says reviewers "shall deny claims when the requested documentation to support payment is not received by the expected time frame." The letter must tell you the date a reply is due, so use the date in the letter and do not rely on counting from memory.

A no-response denial is not a quiet outcome. CMS tells contractors to deny with group code CO, CARC 50 and RARC M127, "Missing patient medical record for this service," which looks like a medical necessity denial on the remittance even when the real problem was a missing packet.

Is it a prepayment or a post-payment review?

Look at whether the claim has been paid. CMS defines prepayment review as a claim determination made before payment, which always results in an initial determination, and post-payment review as a determination made after the claim has been paid, which either leaves the payment unchanged or produces a revised determination showing an overpayment or underpayment.

That difference changes the stakes. On a prepayment ADR the claim is waiting and nothing has been recouped. On a post-payment ADR from a RAC, a finding leads to a demand and recoupment, which is covered in how to respond to a RAC audit and appeal findings.

What should you do on the day the letter arrives?

1. Log the receipt date and the due date. Calendar the due date from the letter, and set an internal date two weeks earlier.
2. Copy the letter. CMS recommends attaching a copy as the first page of your response so the records are matched to the claim.
3. List the claims and dates of service. Read what the letter says it is reviewing and why it was selected; the letter must give the reason, the action, the due date, the consequences and the accepted submission methods.
4. Find who holds the records. The billing provider is ultimately responsible for sending them, even when the treating physician or another clinician holds the chart. Ask clinicians for their notes at once.
5. Check the address. ADRs go to the address on file. CMS says to update the Medical Review Correspondence Address in PECOS so letters reach the right desk.

What belongs in the response packet?

Send the documents that support the services billed for the dates under review, and send them as a complete, ordered set. CMS says the packet may include documentation from before the review period, and it tells contractors to base the determination on the medical record and any documents requested.

• The order, the notes, the results and the discharge or visit summary that prove each service and the medical need.
• Signed and dated entries. If a signature is missing or illegible, CMS accepts a signature log, or a signed and dated attestation statement from the author of the entry that identifies the beneficiary. Later amendments, corrections and delayed entries must show their own date and author and be clearly denoted.
• Full progress notes, not template check boxes alone. CMS discourages templates with limited options, because they often fail to capture enough clinical detail to show coverage and coding requirements are met.
• Billing support when relevant: the claim copy and, for hospital claims, the itemized charges and the discharge status.
• A short cover index listing each document and page count.

A signature fix has its own clock. When a contractor asks, you have 20 calendar days to send an attestation or log, and the review is extended by 15 calendar days after you send it, though these timeframes do not apply to CERT. The same page-by-page approach is used in the pre-bill review in the pre-bill checklist for hospital claims.

How do you send it so you can prove delivery?

Use a method the letter accepts, and keep proof. MACs, CERT, SMRC and RACs must accept paper, fax, CD or DVD, esMD and the contractor's website portal.

• Portal or esMD: save the confirmation. For esMD, CMS uses the esMD Cloud receipt date as the date the documents were received.
• Mail: use a trackable method; CMS encourages contractors to give a physical address and says paper may go by US Postal Service, FedEx, UPS or certified mail.
• Fax: keep the confirmation page for every transmission.
• Pages: number them, and note the count in the cover index so a missing page is visible.

What if you miss the date or the claim is denied?

Ask for more time before the date passes, and appeal if a denial follows. Contractors may accept records after the deadline for good cause, which CMS defines as events like natural disasters or interruptions in business practices, and CMS encourages providers to work with the MAC if more time is needed.

• MAC. If records arrive after a denial, generally within 15 calendar days of the denial date, the MAC has discretion to reopen, and then decides within 60 calendar days of receiving the documentation.
• RAC. A RAC does not reopen a claim after it has denied it, but it keeps late records for the appeal.
• Appeal. A denial is appealable. Redetermination must be filed within 120 calendar days of receiving the notice, under 42 CFR 405.942; see the five levels of Medicare appeals.

How Nucleus Align handles ADRs

Our billing and coding audits team keeps audit deadlines on one calendar, builds the indexed packet with your staff and checks each page against the claim before it goes out. For hospitalist billing groups and hospitals, the wider preparation is in hospital billing audit readiness. Book a call to set up an ADR calendar, or return to the blog.