Responding to a Hospice ADR

National Government Services performs medical review audits of services billed to Medicare to validate that the documentation supports coverage and level of services billed.

When you receive an ADR, it is important to review the entire request carefully for information regarding what documentation needs to be returned to ensure proper payment is made.

We ask that you only send the documents requested and only for the dates of service specified on the ADR. Sending in more information than requested slows down our process here at NGS.

Tracking Your ADRs

It is the providers' responsibility to develop and implement quality processes within its organization to ensure they are receiving and responding to ADRs within a timely manner.

We ask that you respond to ADRs within 35‒40 days of letter date to prevent an unnecessary denial. (CMS allows providers 45 days of the ADR date). Take advantage of our ADR Timeline Calculator tool available on our website.

Did you know you can view and print ADRs from the FISS/DDE Provider Online System? Visit our website for step-by-step instruction.

• • Common status locations:
  • SB6001- Claim suspended for medical review - ADR generated
  • SM5REC- Medical records received and the claim moved to a medical review
  • PB9997- Claim paid
  • DB9997- Claim denied

Note: If the claim denies with 56900, the claim was denied because the medical records were not received within 45 days after the ADR was generated. If you sent your medical records to the contractor and received a 56900 denial, continue to monitor. Records may be in the mail or waiting in distribution to be scanned. If the claim does not move to a medical review location, please contact the Provider Contact Center.

What Can You Do to Prepare?

• • Organize your records
  • Conduct a quality review of your documentation and review for:
    • Legible signatures (suggestion: submit a signature log for illegible signatures if needed)
    • Documents and signatures are appropriately dated
  • Ensure the records are sequenced appropriately
  • If double sided records, copy both sides of the records

What Documentation Should Be Sent In For Review?

When responding to a Hospice ADR, it is important to send enough documentation to demonstrate that Medicare coverage criterion has been met and the beneficiary is eligible for the Medicare benefit. Below is a list of required, and recommended, documents to send in response to a Hospice ADR.

Potential Hospice Documentation Requirements:

• • Hospice election form/signed election statement by the beneficiary
  • Hospice certification/recertification, include initial and all subsequent physician’s certifications. Ensure the applicable physician’s narrative summaries and face-to-face documentation are included (If the attending physician and/or the Medical Director has a Physician that signs the certification form in their absence, please clearly identify who is signing for whom.)
  • Hospice initial admission assessment documentation
  • Recertification evaluations (if applicable)
  • Hospice plan of care
  • Physician progress notes and orders (signed)
  • Documentation/notes for all services provided, can include but is not limited to: nursing, therapy, social services, volunteer
  • Interdisciplinary team documentation
  • Medication administration record including dosing schedule
  • Revocation of hospice election, if appropriate
  • Documentation of any change in hospice status
  • Hospice discharge documentation, if appropriate
  • Please include the medical records/documentation for the previous 30 days from the claim's billed dates of service.
  • Documentation of required face-to-face encounters with the patient as described in the CMS IOM 100-02, Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance; Section 20.1, “Timing and Content of Certification”
  • *If there is an ABN on file please submit the ABN with the requested documentation

NGSConnex is the preferred method for ADR response submission. If you mail in your ADR, please send each response separately and attach a copy of the corresponding ADR. If you must send multiple responses at once, each response must be individually bundled with a copy of the corresponding ADR place on top.

Please remember, as a provider and a HIPAA-covered entity, you must respond to an ADR with the minimum required information necessary to support the services billed. NGS has seen many submissions in response to an ADR for an appealed claim that exceeded 800 pages of information which appears to be a patient’s entire chart. Please know that this is not an acceptable practice.

Posted 3/30/2021