Medicare ADR's and RAC Audits

Additional Development Requests
 
When a Medicare contractor (MAC) cannot make a coverage or coding determination from the information that has been provided on a claim and its attachments, then the facility may be asked  for additional documentation and receive an Additional Development Request (ADR). The MAC  requests records related to the claim(s) being reviewed, and may collect documentation related to the patient's condition before and after a service in order to get a more complete picture of the patient's clinical condition.

Each MAC should have a location on their site addressing ADRs to assist providers with this process. Please note that this process does not include requests generated by Recovery Audit Contractors (RAC), Quality Improvement Organizations (QIO), Comprehensive Error Rate Testing (CERT), and non-medicals such as National Provider Identifier (NPI) issues.

The Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) functions allow all providers to view ADRs online. If you are set up to submit claim attachments electronically, you must use the online system to identify claims and view the ADRs. When an ADR is generated in the system, most MACs will not send a hardcopy ADRs for claims pending.  It is imperative that the business office routinely search for ADRs and notify the necessary team members in the building.
 
Documentation must be as complete as possible to allow medical reviewers to determine the appropriateness of the billed services. Providers should gather all requested information and submit the medical records by the due date on the ADR.

If all information requested in the ADR is not submitted, the claim could be denied. Submitting complete documentation will help decrease the number of denials because the "documentation needed to make a determination is missing," and will help decrease the number of appeals which are a result of incomplete documentation. If no documentation is received within 45 days of the ADR date, then the system will deny the claim. To determine what documentation is necessary, utilize the Local Coverage Determination/National Coverage Determination databases. Claims will be reviewed and processed based on the documentation submitted in response to an ADR.
 
Providers who do not respond in a timely manner will continue to have a high denial rate, and will be candidates for increased or continued medical review.