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Tips for Responding to a Hospice ADR

National Government Services performs medical review audits of services billed to Medicare to validate that the documentation supports coverage and level of services billed. If one of your claims is selected for review, you will receive an ADR letter. CMS gives providers thirty days to return medical records to the MAC when an ADR is generated. It is imperative that providers submit the correct documentation in the allotted timeframe to avoid unnecessary denial of payment.

When you receive an ADR, review the entire request for information regarding what documentation needs to be returned.

Suggestions for Preparing Your Medical Records

  • Organize your records
  • Quality review your documentation for:
    • Legible signatures
      • May submit a signature log for illegible signatures
    • Documents and signatures are appropriately dated
    • Make sure the ADR is on top of the records, and the ADR is for the corresponding medical records
  • Paginate the records
  • Copy both sides of the records
  • Track your ADRs and respond with documentation within thirty days

When Preparing Medical Records Do Not

  • Highlight any part of the documentation in the records
  • Attach sticky notes on the medical records
  • Add tabs to medical records
  • Alter the medical records
  • Bind more than one record together with a clip or rubber bands

Track Your ADRs

The table below shows the status locations for the FISS. It is important that providers respond timely to an ADR request; a claim will deny in the system if it is not received within forty-five days. Providers need to develop and implement quality processes within their organization to ensure they are receiving and responding to ADRs within a timely manner.

Status Location Description of Location
SB6001 Claim suspended for medical review - Additional documentation request generated
SM5REC Medical records received and the claim has been moved to a medical review location
PB9997 Claim paid
DB9997 Claim denied

Note: If the claim denies with MSN 56900, the claim was denied because the medical records were not received by the contractor within forty-five days after the ADR was generated. If you sent your medical records to the contractor and received a 56900 denial, continue to monitor the claim for another five to seven days. Records may have been received after the forty-five day time limit and are in the mail and distribution center waiting to be scanned and moved to a medical review location. If the claim does not move to a medical review location, please contact the Provider Contact Center.

Please have the following information available regarding the claim and documentation when you call the Provider Contact Center:

  • PTAN, NPI and Tax ID number
  • Claim information such as the HICN and date of service
  • The date records were submitted
  • If applicable, any mailing tracking identification numbers

What Documentation Should Be Sent?

When responding to a hospice ADR, it is important to send enough documentation to demonstrate that Medicare coverage criterion has been met and the beneficiary is eligible for the Medicare benefit. Below is a list of required and recommended documentation to send in response to a hospice ADR.

Required Documentation

  • Valid beneficiary NOE
  • Documentation of the oral/written certification (when applicable)
  • Valid written PCTI
    • Initial certification
    • Subsequent certifications
  • Face-to-face documentation (when applicable)
  • Plan of care
  • IDG team meeting notes
  • Nursing and physician notes

Suggested Documentation (Highly Recommended)

  • Physician progress notes from the attending physician or any documented consulting physician’s notes that help support the terminal prognosis
  • Ancillary staff documentation such as the clergy, social worker, hospice aides or therapy notes
  • Any diagnostic work-ups that might be available such as x-rays or lab results
  • Facility documentation from inpatient admissions, admission or discharge summaries

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Tips for Responding to a Hospice ADR
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