ADR Required and Optional Elements

3.2.3.4 - ADR Required and Optional Elements (Rev.: 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) This section applies to MACs, RACs, CERT, and SMRC, as indicated. • The MACs, RACs, CERT, and SMRC shall use discretion to ensure that the amount of medical documentation requested does not negatively impact the provider’s ability to provide care. • The RACs shall issue Additional Documentation Requests (ADR) in accordance with limits established by their Contracting Officer’s Representative (COR) for each calendar year. • The MACs, RACs, CERT, and SMRC, shall request records related to the claim(s) being reviewed and have the discretion to collect documentation related to the beneficiary’s condition before and after a service. • The MACs, RACs, and SMRC have the discretion to issue as many reminder notices as they deem appropriate. Reminder notices can be issued via email, letter, phone call, or equivalent method. At a minimum, the RACs must follow reminder notice instructions prescribed by their SOWs. • The CERT shall issue reminder notices in accordance with its SOW. • The MACs, RACs, and SMRC shall not target their ADRs to providers based solely on the provider’s electronic health record status or chosen method of submitting records. When requesting documentation for post-payment medical review, the MACs, CERT, SMRC and RACs shall use the unified post-payment ADR letter format. Contractors shall maintain the format of the letter but have the discretion to insert case-specific information. In other words, contractors shall not change the order of the sections on the letter but should modify the text underneath each section to provide detailed information and accurately reflect the information specific to the subject of the letter. The detailed text in the Exhibit 46 templates serves only to provide an example of what types of information belong under each section heading. The templates show the format and order contractors shall use when constructing post-payment ADR letters. If any of the elements are lengthy, contractors have the discretion to utilize an attachment to provide the details. If a contractor does not have attachments but has supplementary information to provide in the text of the letter, the contractor should insert the text beneath the section title “Attachments / Supplementary Information”). The MACs, RACs, CERT, and SMRC shall include the following elements in their ADRs and shall use the appropriate templates provided in Exhibit 46: A. Introductory Paragraph • CMS as the government agency making the request; • The program making the request (e.g. the MAC program, the SMRC program, the Recovery Audit Program, the CERT program); and • The regulations and/or laws that apply to the request. The first paragraph in the ADR may identify the following: • The program purpose; • Where additional information about the program and regulations can be found, for example, a website reference; and • Additional program information that may be helpful to the provider or supplier. B. Reason for Selection The reason the provider or supplier was sent the ADR letter and notes about the claims under review. C. Action The action(s) the provider or supplier shall take as a result of receiving the ADR letter. D. When The date a provider/supplier shall reply to the ADR letter and submit the documentation to the contractor. E. Consequences The consequences if the provider or supplier fails to submit the requested documentation. F. Instructions Instructions and notes that will help the provider or supplier respond to the ADR letter. G. Submission Methods The methods the provider or supplier can submit the requested documentation. H. Questions Contractor contact information for provider inquiries related to the ADR. I. Attachments / Supplementary Information • If there are attachments or other supplementary information associated with the ADR, provide a listing of the attachment titles or provide the supplementary information.