Additional documentation request (ADR)

A claim on its own seldom proves that a service was reasonable and necessary. When a reviewer selects a claim and cannot decide it from the claim, its attachments and the billing history, it asks the provider for records by issuing an ADR. The term covers requests in both prepayment and post-payment review, and the senders include MACs, the CERT contractor, Recovery Audit Contractors, the Supplemental Medical Review Contractor and Unified Program Integrity Contractors¹. What counts as additional documentation is broad: progress notes, consultations, physician office and hospital records, test reports, supplier, lab and ambulance records, and any record a reviewer needs from the biller¹.

The request is your checklist. Reviewers are told to name only the individual documents they need to make a determination, and MACs, RACs and the SMRC also send requests electronically through esMD to providers who have registered for them¹. You can also send records before anyone asks by following the PWK process; the MAC then allows 7 calendar days from receipt of the claim, or 10 for mailed documents, before it issues an ADR on that claim¹.

An ADR is not a denial, but an unanswered one becomes one. Providers have 45 calendar days to answer a MAC, RAC or SMRC request and 30 to answer a UPIC. With no response, the claim is denied as not reasonable and necessary, and the remittance carries group code CO with CARC 50 and RARC M127¹. The fix from there is a redetermination with the records that should have gone out the first time. Give every ADR one owner and one due date the day it lands, whatever channel it arrives through.