A Review of the ADR ProcessADR=Additional Documentation Request – a request for the medical records to support the medical necessity of the charges billed on a claim – currently either a Medicare claim or an insurance claim.
- Jennifer Howdyshell will send an e-mail notifying RehabCare, the facility administrator, the regional directors for the facility, and the home office Medicare billers that a claim has been suspended for ADR.
- If the Facility receives a letter in the mail for Additional Documentation Request,this letter should be emailed to Jennifer Howdyshell immediately. We may not know this is happening until you send us the letter!Letter # 1.
- Jennifer will send the ADR e-mail including a copy of the claim (UB-04), the online claim summary (print screens from the claim billed in Medicare), and the ADR Notice with its list of required documents. These 3 items must be included in the final ADR packet.
- You have 20 days unless otherwise specified to gather, have reviewed, and send the information. Medicare (or CGI or Strategic Health Solutions – hired by Medicare) must receive it within 30 days.
- Gather the required documents as detailed on the ADR letter. The RehabCare ADR Coordinator will send an e-mail to the administrator and team with an attachment containing the therapy documents. This must be added to the ADR packet. Remember, the facility still has to add any other documents required to the packet. Medicare Part A claims require much more documentation from the medical record than just what therapy sends. See Medicare Part A Documentation Checklist.
- Make sure you also review the packet for completion.Check with your Regional to see how they want to review this information prior to sending.
- Make sure you always keep a copy of what you send as you will need it again. Mail the packet certified return receipt so you have proof it was mailed timely. Mail it to the correct address as shown on the ADR notice. Note the resident’s name on the receipt and month of claim on receipt as well, for tracking.
- All Insurance ADR claims: the information you are going to send should be sent to Jill West or as directed in e-mail from Jennifer.
- Jennifer monitors these claims in Medicare.You mayreceive a Post Payment Review Results letter at the facility for any RAC ADR claims. Please send a copy of this letter to Jennifer.Letter #2. If the ADR is not a RAC ADR but is for a current claim, there will not be a letter until after an appeal is done.
- Jennifer will notify everyone necessary that the claim has paid, partially paid, or denied. When a claim denies, Cheryl Clemens and the ADR coordinator are notified, so the ADR coordinator will automatically register the denial. If any further documentation is needed, the ADR coordinator will contact the therapy director.
- For a Medicare Part A or Insurance Part A ADR, the Administrator will only have 5 DAYS from Date of DenialTO GET THIS PACKET to RehabCare. You only need to send any documents that did not come from the ADR Coordinator with the denial registration form.The Administrator mails or scans and e-mails this information to Cheryl at Rehab Care to the address on the Denial Registration Form. Cheryl will do the appeal and send the appeal to Medicare.
- For current or new ADRs, if the therapy documents were handled by the ADR coordinator in the first place, Rehabcare should already have the therapy packet. All they will need is any additional documentation that the facility added at ADR. This information should go to
- The facility will receive the results of that appeal in the mail at the facility. Sometimes these are addressed to Cheryl Clemens and/or Kristin Barnes.This is Letter # 3.
- Send the letter you receive to Jennifer Howdyshell at home office. Jennifer will email everyone who needs to be informed of the letter. Cheryl with RehabCare will take it from here and send the next appeal.
- You will then receive another letter stating whether or not the decision is favorable or unfavorable. If favorable, you are now DONE. Send a copy of the letter to Jennifer Howdyshell. If unfavorable, we appeal again. Letter #4.
- Cheryl will file another appeal to the ALJ if the next appeal fails.
- Facility is now done.
We have to receive the letters in order to proceed to each next level of appeal. These letters could make the difference between us keeping the Medicare payment, or having thousands of dollars taken back. Please watch for letters and be sure to send them immediately.
RAC ADR: This is a Medicare claim from the past that was already billed and paid, and is now being reviewed again to see if the documentation supports the billing. RAC refers to “Recovery Audit Contractor” and is a group of auditors hired by the government to recover payments already made on claims if the documentation does not support the medical necessity of the services provided. The RAC ADRs we have experienced were for Medicare B claims.
Pre-Payment ADR – or, a review of documentation for a current claim – this ADR requires that we send the required medical records BEFORE we are paid for the claim. These are generally done by Medicare. These could be for Medicare A claims or Medicare B claims.
Post-Payment ADR a review of documentation for a claim we have already been paid for. Currently we are seeing these for Medicare A claims being reviewed by Strategic Health Solutions, a company hired by Medicare to review.