ADR Timeliness Calculator
Additional Documentation Request (ADR)
When a Medicare claim that is being processed requires additional information, Noridian will send an Additional Documentation Request (ADR) letter requesting the supplier send information to support the claim being billed. These ADR letters are not denial letters. The claims referenced in the letter are pending in the claims processing system, waiting for a response to the ADR.
- Sample ADR Letter [PDF]
Responses to development letters should be returned promptly to avoid processing delays and must be submitted within the timeframe documented in the letter to avoid claim denials. The suspended claim will deny as provider liability for all services billed if the ADR is not received timely. Noridian is not allowed to reimburse providers for costs related to submission, copying or mailing of the documentation.
If a supplier finds a specific HCPCS is routinely selected for an ADR, the supplier may elect to use the Paperwork, or PWK, process.
Make sure you are billing with the appropriate modifier. For example, a non-insulin dependent beneficiary needs to be billed with Modifier KS.
- A supplier may have several claims in which Noridian is asking for same documentation. Each letter with its response must be returned so it can be matched to corresponding claim
- Make sure all documentation requested is returned along with letter
- Make sure documentation is legible, signed by author, and a clear copy is sent
- Make sure documentation is current and pertains to codes being billed
- Do not highlight information. Highlighting shades the information when a document is faxed or imaged, making it difficult to read
- Make sure documentation is being sent to correct DME Medicare Administrative Contractor.
- Noridian often receives responses to ADR letters ZPIC has mailed; which delays processing and may result in denials
- Only send documentation once per ADR letter
- If a claim has denied due to lack of a response within allotted 45 day timeline, suppliers can initiate a Redetermination. A Redetermination request form should not be submitted with ADR response
- Do not submit replacement/duplicate claims for ones pending an ADR response as this action will result in claim denial, rejection or recoupment and will prolong decision making process. When claim is finalized, claim will have paid in full, partially paid, or denied as communicated through a Remittance Advice (RA). If you disagree with decision, you can request a Redetermination within 120 days of date on RA
Noridian Medicare Portal (NMP) Submission
Suppliers can use the portal to:
- view a listing of claims pending an ADR response,
- view a copy of the ADR letter mailed,
- respond to the ADR by browsing their computer files and uploading the necessary documentation in various file formats, and
- viewing the recent receipt of ADRs submitted through any submission method for pending ADR claims.
Using the portal saves time and costs associated with print or fax submission of the ADR response.
- Place ADR letter on top of medical documentation for each claim or a provider generated letter/form which includes facility contact, beneficiary's HICN, facility name and provider number, Claim Control Number (CCN) and DOS.
- Each claim, including all documentation requested must be faxed individually for proper identification of claims.
- When faxing documentation, wait for the first fax to be completely sent prior to sending in the second ADR. Failure to allow adequate time between each faxed claim may cause separate claims to be combined together and potentially cause delays with the claim review and processing.
- Documentation should be full sheets of one-sided paper rather than half sheets or double sided paper to ensure information is received properly through fax line.
- If document is too large for your fax machine's capacity to send all information in one transmission, refer to postal mail or CD mailing process.
- Documents larger than 200 pages can create difficulties with fax line. Noridian encourages providers send documents larger than 200 pages either hardcopy or via CD.
Postal Hardcopy Submission
All documentation that is submitted hard copy should follow these guidelines for an ADR submission to help Noridian receive and review the documentation in an efficient manner.
- Place a copy of ADR as first page on documentation packet. A supplier-generated letter which includes the beneficiary Health Insurance Claim Number (HICN), dates of service (DOS) and a clear identifier that this claim is in response to an ADR request may be substituted for a copy of the ADR letter.
- If you are responding to multiple ADR requests, clearly separate the documentation for each claim. Staple or clip documentation for multiple claims separately with claim identifying data clearly indicated on top sheet for each claim. This allows for several to be sent in one envelope or package.
- Copies should be full sheets of one-sided paper rather than half sheets or double-sided paper. If your facility uses double-sided forms, verify beneficiary's name is on each sheet of paper submitted.
All documentation should be returned to address and specific Post Office (PO) Box as indicated on the ADR letter.
In order for Noridian to accept ADR receipt on the CD, providers must follow all of the following requirements for submission by CD. Failure to follow all of these instructions may result in delay of claim/documentation processing.
- Images must be submitted in PDF or multi-page TIF format. Image of PDF or TIF file should include ADR letter of claim requested and all requested items in ADR. The ADR letter should be first item on image of file indicating HICN, CCN and DOS for claim being submitted to ensure accurate identification of submitted records. No paper correspondence should be sent when mailing CD package.
- Multiple ADRs may be submitted on same CD, however each separate ADR should be in a separate PDF or TIF file. If ADR records cannot be imaged in one file due to size of medical record, then you must indicate image name method below.
- Image file names should begin with appropriate HIC and CCN values for record separated by commas. HICN and CCN values can be found on the letter you received requesting records.
- Images must be contained in a password-protected ZIP file. You can either include all images in one ZIP file or use multiple ZIP files (for instance, if you need to put one image per ZIP). If you use multiple ZIP files, password must be same for all ZIP files on same CD/DVD.
- All ZIP files must be placed in root location of CD/DVD. There should be no folders on CD/DVD; only thing on CD/DVD should be one or more ZIP files. Names of ZIP files themselves are not important and can thus be names in any way desired.
- Passwords must meet the following requirements:
- Passwords must contain at least one upper case letter of alphabet
- Passwords must contain at least one lower case letter of alphabet
- Passwords must contain at least one number
- Passwords must contain at least one special character e.g. %,@,#, etc
- Passwords must be at least 8 characters long
- Passwords must not include words or names
- CD may be mailed by any method the provider chooses; however, Noridian suggests sending via a tracked mailing service.
- Email password, mail tracking number (if applicable) and date sent to email address: email@example.com. Email should be sent same day CD is mailed or next day at latest.
Additionally, Noridian recommends the following safeguards for mailing confidential information by CD:
- CD should be labeled or indicate "restricted and/or confidential" on it.
- A record of shipment should be maintained so if package is lost, its contents can be recreated.
- CMS Internet Only Manual (IOM), Publication 100-08, Chapter 3
- CMS Medicare Learning Network (MLN) Matters (MM)7254 : Contains information regarding esMD and the Documentation Case ID
- MM8583 : Contains information regarding the 45 day response timeline
Last Updated Nov 10, 2017