Providers Have a New Timeframe to Respond to ADRs

April 7, 2015 by  
Filed under UPIC Audits

healthcare-questions(4/7/15)  On February 4, 2015, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 567, Change Request 8563, which tightened the timeline for Medicare providers and suppliers to respond to Medicare Administrative Contractor (MAC) and Zone Program Integrity Contactor (ZPIC) requests for Additional Documentation Requests (ADRs). Providers and suppliers are now limited to a 45 calendar day timeframe to produce the additional requested documentation. Moreover, they should no longer expect that a request for an extension of time will be granted.

CMS review contractors – such as MACs and ZPICs – may not have enough information to make a determination on a claim under review. In these circumstances, the CMS contractors have the right to request additional documentation from the provider or supplier through an ADR.[1] Unless providers and suppliers furnish the additional requested documentation, no payments may be made for claims under review.

Moreover, when requesting documentation for prepayment review, the MAC and ZPIC must notify providers that the requested documentation is to be submitted within 45 calendar days of the request.[2] Importantly, extensions will not be granted to providers who need more time to comply with the request. Claim reviewers will also deny claims for which the requested documentation was not received by the 46th day.

Medicare providers and suppliers should take efforts now to ensure that their billing staff and compliance personnel are aware of these important timing changes. If you have any questions regarding an ADR issued by a MAC or ZPIC, please feel free to give us a call today. We would be more than happy to assist you in these as well as other compliance-related matters.

IMG_1891Robert Saltaformaggio, Esq. is a health law attorney with the boutique firm, Liles Parker, Attorneys & Counselors at Law.  Liles Parker has offices in Washington DC, Houston TX, McAllen TX and Baton Rouge LA.  Our attorneys represent health care professionals around the country in connection with government audits of Medicaid and Medicare claims, licensure matters and transactional projects.  Need assistance?  For a free consultation, please call: 1 (800) 475-1906.

[1] Social Security Act, Section 1833(e)

[2] Pub 100-08, Medicare Program Integrity Manual Chapter 3, Verifying Potential Errors and Taking

Corrective Actions, Section

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