Tuesday, December 2, 2014

CMS Instruction on Prepayment ADRs Released

Dianne De La Mare


The US Department of Health and Human Services, Center for Medicare & Medicaid Services (CMS) has released a revised Medicare Learning Network (MLN) Matters article, New Timeframe for Response to Additional Documentation Requests, which instructs Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) to notify providers that they must submit their prepayment Additional Documentation Requests (ADRs) within 45 calendar dates from the initial MAC/ZPIC request date.

MACs and ZPICs also must notify providers that failure to respond to a prepayment review ADR within the 45-day timeframe will result in a denial of the claim. The effective date is April 1, 2015.

CMS review contractors (MACs, ZPICs, Recovery Auditors, etc.) are not always able to make a determination on a claim based solely on the information on the claim. In those instances, CMS review contractors will solicit documentation from the provider or supplier by issuing an ADR. CMS review contractors are authorized to collect medical documentation.

The ADR requirements must notify the provider that: 1) no payment will be made to the provider if they have not furnished the information requested in an ADR; and 2) when requesting documentation for a prepayment review; MACs and ZPICs must notify providers that the requested documentation must be submitted within 45 calendar days of the request, or providers claim will be denied.

To obtain the complete copy of the MLN article go to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8583.pdf.

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