Medicare Contractors Additional Documentation Requests (ADRs)
Transmittal 10197: Clarifying Authority to Request and Require Documentation
CMS issued two Transmittals in June detailing updates being made in the Medicare Program Integrity Manual. This article highlights changes to Chapter 3 – Verifying Potential Error and Taking Corrective Actions. A related article in this week’s newsletter highlights changes to Chapter 6 – Medicare Contractor Medical Review Guidelines for Specific Services.
Transmittal 10197 (Change Request (CR) 11730) was issued on June 26, 2020. The purpose of this CR is to clarify CMS’ authority to request and require documentation, upon request, to determine the appropriateness of claims for payment. Changes are being made in the following two sections of Chapter 3:
- Section 126.96.36.199: Time Frames for Submission, and
- Section 188.8.131.52: No Response or Insufficient Response to Additional Documentation Requests (ADRs).
Under the General Information section of this Transmittal CMS notes the following:
- There are times when Medicare Contractors (MACs, Comprehensive Error Rate Testing (CERT), Supplemental Medical Review Contractor (SMRC), Recovery Audit Contractor (RACs), Unified Program Integrity Contractors (UPICs), and other contractors may not be able to make a pre- or post- payment determination based on information available on the claim, its attachments, or the billing history when applicable. When this happens a Contractor may require a provider or supplier to submit medical and related supporting documentation to determine payment amounts due. “CMS and its contractors require that sufficient documentation and information be furnished to support that selected claims meet applicable coverage, coding, and billing requirements for payment.”
- When a Medicare Contractor sends a provider an Additional Documentation Request (ADR), they request information be provided within specified time frames. “In cases where no supporting documentation is received to conduct a medical review, the claim shall be denied.”
Section 184.108.40.206: Time - Frames for Submission
Current Manual Guidance: This section applies to MACs, RACs, CERT, and ZPICs as indicated.
Effective July 27, 2020: This section will apply to MACs, RACs, CERT, SMRC, and UPICs, as indicated.
Current Manual Guidance: There is no additional information prior to subsection A.
Effective July 27, 2020: Contractors will be required, “when authoring correspondence related to ADRs, to cite sections 1815(a), 1833(e), and 1862(a)(1)(A) of the Act exclusively when referring to the authority for requiring submission of documentation.
“Contractors are authorized to collect medical documentation by the Social Security Act (the Act).
Section 1815(a) of the Act states that "...no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period."
Section 1833(e) of the Act states that "[n]o payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period." In addition, Contractors are required to ensure that payment is limited to those items and services that are reasonable and necessary.
Section 1862(a)(1)(A) of the Act states that “[n]ot withstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services— which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Subsection 220.127.116.11.A: Prepayment Review Time Frames
Current Guidance: MACs and ZPICs
- Shall notify providers that documentation requested is to be submitted within 45 calendar days of the request,
- Should not grant an extension to providers who need more time to comply with the request, and
- Shall deny claims for which the requested documentation was not received by day 46.
Effective July 27, 2020: MACs and UPICs
- Shall notify providers “when they expect documentation to be received,”
- Should not grant extension to providers who need more time to comply with the request, and
- Shall deny claims “when” the requested documentation “to support payment is not received by the expected timeframe.”
Subsection 18.104.22.168.B: Post payment Review Time Frames
Current Guidance: MACs, CERT, and RACs, ZPICs
- MAC, CERT, and RACs shall notify providers that documentation requests is to be submitted within 45 calendar days of the request.
- ZPICs requesting documentation shall be within 30 calendar days of the request.
- Since there are no statutory requirements for when post payment reviews are to be completed, “MACs, CERT, and ZPICs have the discretion to grant extensions to providers who need more time to comply with the request. The number of extensions and the number of days for each extension is solely within the discretion of the MACs, CERT and ZPICs. RACs shall follow the time requirements outlined in their SOW.”
Effective July 27, 2020: MACs, CERT, SMRC, UPICs and RACs
- “Shall notify providers when they expect documentation to be received.”
- “MACs, CERT, SMRC, UPICs and RACs have the discretion to gran extensions to providers who need more time to comply with the request. The MACs, CERT, SMRC, UPICs and RACs shall deny claims when the requested documentation to support payment is not received by the expected timeframe (including any applicable extensions).”
Subsection 22.214.171.124: No Response or Insufficient Response to Additional Documentation Requests
Current Guidance: This section applies to MACs, RACs, CERT, and ZPICs/UPICs, as indicated.
Effective July 27, 2020: This section will apply to MACs, RACs, CERT, SMRC, and UPICS, as indicated.
Subsection 126.96.36.199.A.: Additional Documentation Requests
Current Guidance: Information is to be provided with 45 calendar days for MACs and RACs or 30 calendar days for ZPICs/UPICs after the date of request (or within a reasonable time following an extension). If not received, the contractors “shall deny the claim, in full or in part, as not reasonable and necessary.”
Effective July 27, 2020:
The following sentence has been added to the beginning of this section:
- “The reviewer authority to request that documentation be submitted, to support claims payment, is outlined in Section 188.8.131.52 of this chapter.”
Also, specific calendar day timeframes have been replaced with the following:
- “If information is requested from both the billing provider or supplier and/or a third party and no response is received within the expected timeframes (or within a reasonable time following and extension), the MACs, RACs, SMRC, and UPICs shall deny the claim, in full or in part, as not reasonable and necessary.”
MACs will be the contractor responsible for counting denials as automated or non-medical record review.
Subsection 184.108.40.206.B: No Response
During Prepayment Review
Current Guidance: A claim shall be denied by MACs and ZPICs/UPICs if no response is received within 45 calendar days after the date of the ADR.
Effective July 27, 2020: Claims shall be denied by the MACs and UPICs if no response is received within “the expected timeframes.”
During Post-payment Review
- For MACs claims will be denied as not reasonable and necessary and count as non-medical record reviews if no response is received within 45 calendar days after the date or the ADR (or extension).
- ZPICs/UPICs shall deny the claim if not response is received within 30 calendar days.
- RACs shall count these as complex or non-complex reviews.
Effective July 27, 2020
- MACs, RACs, UPICs and SMRC shall deny claims as not reasonable and necessary if no response is received within the expected timeframes (or extension).
- “These contractors shall cite sections 1815(a), 1833(e), and 1862(a)(1)(A) of the Act exclusively when referring to the authority for requiring submission of documentation, when denying claims for no response within the expected timeframes.”
- The MACs shall count these denials as non-medical record reviews.
Subsection 220.127.116.11.C.: Insufficient Response
The only change made to this section is that the SMRC has been added to the list of applicable contractors.
Moving forward, closely monitor ADR requests to ensure you provide documentation with “expected timeframes.”
Article by Beth Cobb
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system.
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.