Claim Review Preparation - JD DME
ADR Associated Costs
Note: Noridian is not allowed to reimburse providers for costs related to submission, copying or mailing of documentation.
Claim Review Preparation
When a Medicare claim requires additional information, the contractor will send an Additional Documentation Request (ADR) letter requesting the supplier send information to support the claim being billed.
Responses should be returned promptly to avoid processing delays and must be submitted within the timeframe documented in the letter to avoid claim denials.
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. Visit one of the Browse by DMEPOS Category webpages to find documentation checklists, physician letters and policy specific information pertaining to the specific policy requirements.
While preparing documentation, be sure:
- All documentation requested is returned with the ADR letter.
- Documentation is legible, signed by the author, and a clear copy is sent.
- Documentation is current and pertains to codes being billed.
- Documentation is sent only once.
- Nothing is highlighted. Highlighting shades information, making it difficult to read when faxed or imaged.
- Documentation is being sent to correct DME Medicare Administrative Contractor.
- Noridian often receives responses to ADR letters the UPIC has mailed. This delays processing and may result in denials.
- Documentation is prepared for each ADR letter
- A supplier may have several claims in which Noridian is asking for the same documentation. Return each letter with its response, so it can be matched to the corresponding claim.
- Documentation that is labeled or tabbed helps providers/suppliers validate that all requested records are submitted and ensures reviewers can easily identify each element within submitted documentation.
While a claim is pending an ADR response - Do NOT submit replacement/duplicate claims as this action will result in claim denial, rejection or recoupment and will prolong the decision-making process.
Passed the ADR Timeliness Deadline - A suspended claim will deny as provider liability for all services billed if the ADR is not received within the allotted 45-day timeline. If this occurs, suppliers can initiate a Redetermination. The Redetermination request form should not be submitted with the ADR response.
- CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3
- CMS Change Request (CR) 7254 - Contains information regarding esMD and the Documentation Case ID
- CMS CR 8583 - Contains information regarding the 45-day response timeline
Last Updated Wed, 16 Aug 2023 16:03:50 +0000