Medicare additional documentation requests (ADRs): the 45-day clock, who is asking and what to send

Who sends Medicare documentation requests, and what does each one review?

Five kinds of contractor, all working under chapter 3 of the Program Integrity Manual: the MACs, the Recovery Audit Contractors, the error-rate testing contractor known as CERT, the Supplemental Medical Review Contractor and the Unified Program Integrity Contractors¹. They ask for the same records for different reasons, and the reason tells you what is at stake.

MACs analyze claims for compliance with Medicare coverage, coding and billing rules and take corrective action; serious problems can draw actions such as 100 percent prepayment review, while minor or isolated ones get education¹. The Recovery Audit program is a legislatively mandated program under the Tax Relief and Health Care Act of 2006: RACs identify improper payments on paid claims, and the MACs adjust the claims, recoup overpayments and return underpayments¹.

CERT selects claims at random, so a CERT request can land on an ordinary claim¹. The SMRC performs medical review alongside the others and appears in every ADR rule in the chapter¹. UPICs do program integrity work and send a written notice before a provider-specific review, stating whether it is prepayment or postpayment¹.

How long do you have to respond?

Forty-five calendar days for a MAC, RAC or SMRC request, 45 for a CERT request in postpayment review, and 30 calendar days for a UPIC request¹. The manual cites 42 CFR 405.903 for prepayment review and 405.929 for postpayment review, and it tells contractors to say in the request when they expect the documentation¹.

The clock runs from the date on the request, not the day someone opens the envelope; for RAC reviews the manual counts the 45 days from the date of the ADR¹. A week in a shared inbox is a week of your window gone.

There is some give, but do not plan on it. Contractors may accept documentation received after the 45- or 30-day time frame for good cause, which the manual describes as situations such as natural disasters, interruptions in business practices or other extenuating circumstances the contractor deems good cause¹. A busy month is not on that list. If you send through esMD, the receipt date is the esMD Cloud system’s receipt date, with submissions outside business hours counted the next business day¹.

What happens if you do not respond in time?

If you do not respond to an additional documentation request in time, the claim is denied, in full or in part, as not reasonable and necessary, and the only way back is an appeal. The manual cites 42 CFR 405.930: contractors shall deny claims when the requested documentation is not received by the expected time frame, including any extension¹. For no response, the MACs, RACs, SMRC and UPICs deny the claim in full or in part as not reasonable and necessary, using group code CO, claim adjustment reason code 50 and remittance advice remark code M127 for the missing medical record¹. X12’s code 50 is the payer saying the service was not medically necessary⁵, the label a silent chart earns.

In prepayment review that denial is the initial determination; in postpayment review it becomes a revised determination and an overpayment to recoup¹. Either way the road back is an appeal: a redetermination request within 120 days of the date you get the remittance advice, with receipt presumed 5 days after the notice date, and a MAC decision generally within 60 days of receiving the request². Reconsideration follows within 180 days of the redetermination notice². The Part B appeals post walks each level.

Our view: a CO-50 for no response is the most avoidable denial in Medicare, because the record usually existed. Treat it as a process failure and fix the intake.

What goes in a complete response?

Exactly what the request lists, in the order it lists it, with the request as the first page. The manual tells contractors to specify in the ADR only the documents needed, so the request is your checklist¹. A typical packet has the request and your cover sheet, the signed note for the date of service, the order or referral, the history and plan of care, test results supporting medical necessity, and a signature log or attestation if signatures are illegible.

Send it the way the contractor accepts, and keep a copy of the whole packet and the proof of transmission with the date. A billing audit before the request arrives is the cheapest way to learn which of your notes would not survive one.

How do prepayment review, postpayment review and WISeR pre-payment review differ?

Prepayment review, postpayment review and WISeR pre-payment review differ in timing and consequence: prepayment review holds the claim before payment, postpayment review revisits money already paid, and WISeR adds review before payment for selected items in six states when no prior authorization request was made. Prepayment review happens before payment and always produces an initial determination; postpayment review happens after payment and ends with no change or a revised determination of an overpayment or underpayment¹. Prepayment stops cash; postpayment claws it back with interest on your time.

WISeR is a third pattern for traditional Medicare in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, running from January 1, 2026 to December 31, 2031⁴. For the model’s selected items, you either submit a prior authorization request or go through post-service, pre-payment review, and a claim submitted with no request is subject to medical review before payment⁴. The WISeR post covers the service list.

Home health has its own version. The Review Choice Demonstration runs in Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma, was extended for five years effective June 1, 2024, and lets agencies choose pre-claim review or postpayment review; CMS removed the minimal-review option, and agencies with a 90% provisional affirmation rate on at least 10 requests earn lighter review³. The RCD post has the billing flow.

How do you track requests so none sit in a mailbox?

Track documentation requests with one log, one intake point and one weekly review, so every request that arrives by portal, esMD, fax or mail is logged the day it lands and checked against its due date before it can sit in a mailbox. Every request, whatever the channel, gets a row the day it lands: request date, contractor, prepayment or postpayment, due date computed from the request date, claim numbers, patient, records owner, date sent, method, proof, and outcome. Portal downloads, esMD notices, faxes and mail all go to the same person, who logs before filing.

Then put the log on the weekly billing report: open requests sorted by due date, anything inside ten days flagged, a line the owner reads in five seconds. A dedicated biller handling claim appeals should own the log too, since no-response denials come straight back to them. The trade-off: one intake point is one point of failure when that person is out, so name a backup.

What to do this week

1. List every channel a documentation request could arrive through, and name one person and one backup to check each one daily.
2. Build the request log with a due-date formula: request date plus 45 for MAC, RAC, SMRC and CERT, plus 30 for a UPIC.
3. Write the packet checklist for your most-billed services and store it with the log.
4. Pull the last six months of CO-50 denials with M127 and count how many were no-response rather than a real documentation gap.
5. Check the MAC portal for any open requests you did not know about, and log them today.