Responding to a Home Health Additional Documentation Request (ADR)

Published 02/17/2020

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/Recertification

  • Physician certification that the requirements below have been met
    • Patient needs intermittent SN care, PT, and/or SLP services
    • Patient is confined to home
    • Plan of care has been established and will periodically be reviewed by an allowed physician
    • Services will be furnished while under the care of an allowed physician
    • Face-to-face encounter
  • Physician’s recertification to support claim billed if review is for a subsequent episode/period of care
  • Plan of care for the claim/episode or period of care requested for review
  • Initial (start of care) plan of care/certification should be included for all requests even if review is for subsequent episode/period of care. The plan of care and certification/recertification must be reviewed, signed and dated by the physician (who is qualified to sign as described in 42 CFR 424.22) prior to submitting the final bill for the period of care (each 30-day) or episode under review.
  • The plan of care must include the home health services that are written in an individualized plan that identifies patient specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy or podiatry acting within the scope of his or her state license, certification or registration (42 CFR 484.60 and CMS Medicare Benefit Manual, Chapter 7 Section 30.2.1).
  • Plan of care must cover entire episode or the two periods of care
  • Physician orders not included on the plan of care must be signed and dated prior to billing the final claim to Medicare
  • Physician signatures need to be present, legible and dated, include signature log or attestation if 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
  • If the physician signature is not on every page of the plan of care it must be clear that all pages of the plan of care are associated. For example, each page of the plan of care contains the page number and the total number of pages, such as 'Page 1 of 4,' 'Page 2 of 4,' etc.
  • If a patient’s sole skilled service need is for skilled oversight of the unskilled services, please submit the physician’s brief narrative documentation describing the clinical justification of the need for the service

Face-to-Face Encounter

  • Submit face-to-face encounter document (actual clinical note for the face-to-face encounter visit for admissions on/or after 01/01/2015 (or the narrative for admissions on/or after 04/01/2011 and before 01/01/2015)
  • Face-to-face document should be submitted with all requests even if review is for subsequent episode/period of care
  • Must be completed no earlier than 90 days prior to or up to 30 days after the start of care
  • Face-to-face encounter must be related to the primary reason the patient requires home health services
  • Must be performed by a physician or allowed nonphysician practitioner
  • 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 

Homebound

  • Submit documentation to support homebound first criteria are met
  • Submit documentation to support homebound second criteria are met


Documentation of Services Rendered To Include:

  • Adequate documentation is needed to determine if services billed are reasonable and necessary and to support the Health Insurance Prospective Payment System (HIPPS) code (or level of payment) billed. OASIS assessment used to generate the HIPPS code billed must be present in the national repository.
  • Notes or summary for the disciplines billed 
  • All supplemental orders, appropriately signed and dated
  • Initial therapy evaluation (if applicable)
  • Therapy reassessments/re-evaluations (if applicable)
  • Therapy documentation requirements as follows (as applicable): assessment, measurement and documentation of therapy effectiveness
  • 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
  • Any other pertinent documentation that may be needed to establish that services are reasonable and necessary (e.g., date of hospitalization, medication changes, laboratory values, physician contacts/visits, etc.)
  • Documentation denoting treatment week, when different from calendar week
  • Itemized supply list if billed:
    • Include the quantity and cost of each item
    • All documentation as required in the LCD or NCD as applicable
    • 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

For Targeted Probe and Educate (TPE) Only

  • Please remember to submit the contact information for the person(s) who will be the point of contact for the reviewer to contact by phone for any missing information or to schedule an educational session upon completion of the 20–40 claim sample

How to Submit

  • Include a manifest/list with medical records submitted and send the medical records in secure packaging to ensure the security of medical records — do not send original records
  • If responding to multiple requests in a single package, ensure each response is clearly separated. If responding to more than one date of service on the same beneficiary, send a separate response for each request. 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
  • Submit the medical records to the appropriate address listed below or on the ADR. You may also submit via other avenues outlined below.

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

OR

Home Health Review Choice Demonstration
Mail Code AG-760
P.O. Box 100131
Columbia, SC 29202–3131

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

OR

Home Health Review Choice Demonstration
Mail Code: AG-760
BLDG 1
2300 Springdale Drive
Camden, South Carolina, 29020–1728

  • Records may be sent via esMD (Electronic Submission of Medical Documentation System)
  • Providers may also use eServices to submit responses
    • Palmetto GBA’s eServices is an Internet-based, provider self-service secure application
    • Palmetto GBA’s goal is to give the provider secure and fast access to their Medicare information seamlessly via our website through the eServices application
    • eServices User Guide (PDF, 7.85 MB)
  • Records may also be faxed to (803) 699–2436 (JM MR HHH ADR only)
  • Records may also be faxed to (803) 419–3263 (RCD HH Pre-Claim Review and ADR Responses)
  • Do not include any correspondence other than ADR responses to the medical review department
  • 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
    • When using password protect files on Adobe Security feature (separate from password protect on disk), please also provide the password
    • Email Passwords for Secure Zip or Adobe Security to DISKINFO@Palmettogba.com
    • Please don't create a PDF or TIFF file of each page. One PDF or TIFF file per record is acceptable.
  • The Palmetto GBA Medical Review Department developed a Responding to a Home Health Additional Documentation Request (ADR) checklist (PDF, 37 KB). Please complete this checklist and include it when responding to an ADR. To access this checklist, select the PDF document below.

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