Responding to additional documentation requests (ADRs)

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Home ► adr ► Responding to additional documentation requests (ADRs)

Last Modified: 2/28/2024 Location: FL, PR, USVI Business: Part B, Part A

Responding to additional documentation requests (ADRs)

First Coast sometimes requires a clinical review of documentation to determine the medical necessity of services. It is the goal of First Coast to ensure that providers are properly reimbursed for medically reasonable and necessary services. When documentation is required, an ADR is mailed to the provider’s practice address on file with Medicare. To ensure you are receiving your ADR to the correct address, be sure to update your Medical Review Correspondence Address in the Provider Enrollment, Chain, and Ownership System (PECOS).

Prior to responding to the ADR, providers should:

• Verify patient and/or claim form billing information matches what is requested within the ADR letter

• Ensure legible and appropriate signatures of those who rendered services are included in the documentation

Timeframe for submission of documentation:

• CMS allows 45 calendar days to submit the documentation

• The 45-day timeframe begins with the date of the ADR letter

• If you choose to mail your documentation, allow sufficient time for documentation to be mailed, received, and matched to the claim in question

• Claims are set to automatically deny on day 46 when documentation has not been received

Note: Electronic submission is the most efficient method to send your documentation

Methods of responding to ADR:

• SPOT (registration instructions)

• Secure documentation submission – refer to SPOT User Guide

• esMD

• By fax:

Available for Part A only

Medicare Part A prepay claims ADR fax coversheet

• For Part B claims ADRs you must use the first page of the ADR letter as the coversheet and:

• For Part B pre-pay claims fax to 904-361-0318

• For Part B post-payment claims fax responses to 904-361-0318

• By mail: See ADR letter for mailing address and instructions

First Coast must be able to clearly identify the author of the medical record:

• When the initial response to an ADR does not contain appropriate signatures, a second ADR will be sent requesting the signature log and/or attestation statement. See our signature guidelines—20-day timeframe article for additional information.

• If the signature is missing, an attestation statement must be included to authenticate who authored or contributed to the record

• If the signature is illegible, an attestation statement or signature log must be included to authenticate who authored or contributed to the record

• Response to the request for an attestation or signature log must be received within 20 calendar days from the date of the second request, whether by phone contact or letter.

When documentation is submitted timely, CMS requires the contractor to make a claim determination within 30 calendar days.

Source: CMS IOM, Pub. 100-08 Medicare Program Integrity Manual, Chapter 3 external pdf file

Additional Documentation Request page on CMS.gov external link

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