Third-party ADR

3.2.3.3 - Third-party ADR (Rev.: 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) This section applies to MACs, RACs, CERT, SMRC, and UPICs, as indicated. Unless otherwise specified, the MAC, CERT, SMRC, UPIC and RAC shall request information from the billing provider/supplier. The treating physician or other clinicians should provide any requested or relevant documentation. However, because the billing provider/supplier selected for review is the one whose payment is at risk, it is this billing provider/supplier who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, SMRC, UPIC and RAC. The MAC, CERT, SMRC, UPIC and RAC have the discretion to send a separate ADR to third- party entities involved in the beneficiary’s care. For this purpose, third-party entities are other clinicians, providers, suppliers, etc. involved in the beneficiary’s care but not submitting the associated claim for Medicare payment. A third-party entity is not a billing agent or agency. MACs, RACs and UPICs shall not solicit documentation from a third-party entity unless they first or simultaneously solicit the same information from the billing provider or supplier. The following requirements also apply: • The MACs, SMRC, and RACs shall notify the third-party entity and the billing provider or supplier of the review timeframes in 3.2.3.2. For third party ADRs, the MACs shall allow 45-calendar days for the third- party entity to submit additional documentation (or 30-calendar days for UPIC claims), beginning with the date of the most recent ADR request (be it to the billing entity, or later, third party provider), before issuing a denial per 42 CFR § 405.930. • A contractor may accept documentation received after 45-calendar days for good cause. Good cause means situations such as natural disasters, interruptions in business practices, or other extenuating circumstances that the contractor deems good cause in accepting the documentation. • The MACs and UPICs have the discretion to issue as many reminder notices as they deem appropriate to the third party via email, letter or phone call prior to the documentation due date, as discussed above; • When information is requested from both the billing provider or supplier and a third-party and a response is received from one or both that fails to support the medical necessity of the service, the MACs, SMRC, and UPICs shall deny the claim, in full or in part, using the appropriate denial code. • Refer to §3.2.3.7 for ADRs to ordering providers for lab services.