Understanding ADRs When Participating in the RCD
An ADR is an Additional Documentation Request. This is when a Medicare contractor is asking for medical records to ensure that Medicare requirements are met, such as medical necessity and the elements of eligibility. An ADR can be pre-payment (as in spot check) or postpayment. The 25 percent reduction is unique to PCR. Each ADR will cover one 30-day billing period.
Participation in the Review Choice Demonstration (RCD) does not eliminate the possibility that a home health agency (HHA) could receive an ADR. The HHA can still receive an ADR from our Comprehensive Error Rate (CERT) contractor, the Recovery Audit Contractor (RAC) or the Unified Program Integrity Contractor (UPIC). Please review your ADRs very closely, and make sure your records are sent to the correct contractor.
Additionally, the RCD may utilize an ADR in situations such as, but not limited to:
- If an HHA is enrolled in Choice 2: Postpayment Review; or
- If an HHA is enrolled in Choice 4: Selective Postpayment Review; or
- If an HHA is enrolled in Choice 5: Spot Check Review; or
- If an applicable claim is submitted without a pre-claim review request submission, it will be stopped for pre-payment review
- If a valid UTN for a different period is entered on the wrong claim
How Will I Receive Notification of an ADR?
For your convenience, all Home Health and Hospice providers enrolled in eServices will automatically receive their ADR letters by eDelivery. For a short period of time you will still continue to receive both a mailed hardcopy ADR and the eDelivery electronic ADR in eServices. We will notify you when the hardcopy mailings will be discontinued.
Responding to a Pre-Payment ADR
Final claims submitted under the pre-claim review choice without a pre-claim review request decision on file will be stopped for pre-payment review. If the claim is found payable, it will be subject to a 25 percent payment reduction. The 25 percent payment reduction is non-transferable to the beneficiary and is not subject to appeal. Palmetto GBA will stop the claim and send the ADR through the U.S. Postal Service or eServices. The HHA will have 45 days to respond to the ADR with all requested documentation.
Providers on Spot Check Review will have 5 percent of claims reviewed every six months to ensure continued compliance. This type of ADR review is done via pre-payment review. This is not subject to the 25 percent payment reduction.
Responding to a Postpayment ADR
Once the claim is received, Palmetto GBA will process the claim for payment and send the HHA an additional documentation request (ADR). The HHA will submit all pertinent medical record documentation and other needed documents and records that are necessary in order to conduct a review and reach a conclusion about the eligibility of the beneficiary and medical necessity. The HHA will have 45 days to respond to the ADR. Palmetto GBA will then have 60 days to review the documentation and make a decision. If no response is received from the HHA, notice of an overpayment will be sent to the HHA and payment recoupment procedures will be initiated.
Palmetto GBA will communicate the claim review decision to the HHA. If a claim is denied, the MAC will follow the standard payment recoupment procedures already in place. The HHA retains all appeal rights for denied claims.