As previously mentioned in this manual, many times the denial process starts with an Additional Development Request (ADR).
As previously mentioned in this manual, many times the denial process starts with an Additional Development Request (ADR). These can be triggered by items specific to the patient, such as the RUG score or ICD-9 code billed, or they can be part of a widespread probe. Under probe reviews, contractors may examine 20 – 40 claims per provider for provider-specific problems. Contractors also conduct widespread prove reviews (involving approximately 100 claims) when a larger problem, such as a spike in billing for a specific procedure, is identified.
The team is encouraged to read the ADR letter carefully as there are specific items of documentation requested in these letters. Even if a facility has received ADR letters in the past they need to continue to carefully read each one, as the documentation requirements have been known to change. The following is a sample of the types of documentation requested in ADR letters:
- Initial MDS and any MDS that corresponds to the billed dates of service.
- All physician’s orders, MD certifications, and progress notes for the dates of service in question.
- History and Physical.
- MD Certification/Recertification for skilled stay for billed dates. If a nurse practitioner or clinical nurse specialist signs the certification, also submit a statement verifying no direct or indirect employment relationship with the facility.
- Hospital records that validate a qualifying stay, i.e. discharge summary or transfer documentation.
- Nurses’ notes, resident care plan, treatment records, medication records, and graphics sheets.
- Any other documentation that relates to the condition for which services were rendered that skilled the patient for SNF coverage.
- Documentation of all therapies provided, including
- Evidence of MD supervision, i.e. MD order, signed plan of treatment for therapies.
- Initial therapy evaluations.
- Therapy progress notes.
- Therapy logs that show services, dates, and times for codes billed.
- Include records for MDS look back periods and dates of service billed. This can be up to 30 days prior to the MDS.
- Diagnostic tests performed as an inpatient of the SNF for billed dates.
- Documentation of adjustment to HIPPS codes resulting from MDS corrections related to the dates of service under review.
It is also recommended that the facility include a letter that outlines the argument for payment. This letter should include:
- Brief explanation of the hospitalization (if one occurred).
- Past medical history.
- Status of patient on admission.
- List of the skilled nursing services provided to the patient.
- An explanation of skilled therapy services provided to the patient.
- Medicare guidelines used in the skilled care decision making process (if applicable).
Medicare requires a legible identifier for services provided and ordered. Medicare will accept clearly legible handwritten signatures, handwritten initials, or electronic signatures. Stamped signatures are not acceptable on any medical record. If the identifier is not legible, it is recommended the facility include a signature log with the packet of information they are submitting. The log should contain the typed name of the provider, their credentials, their signature, and their initials.
If the signature requirements are not met the reviewer will conduct the review without considering the documentation with missing or illegible signatures. This could lead to a denial of payment for services.
The facility should compile the information requested and as a team review the record for thoroughness. Medical records are due to the intermediary within 30 calendar days. Non-medical records are due to the intermediary within 14 calendar days. A copy of the ADR letter should be included in the packet.
It is not uncommon for an ADR to result in the denial of part or all of a claim. Once an initial claim determination is made, providers, participating physicians and other suppliers have the right to appeal.
- Physicians and other suppliers who do not take assignment on claims have limited appeal rights.
- Beneficiaries may transfer their appeal rights to non-participating physicians, or other suppliers who provide the items or services and do not otherwise have appeal rights. Form CMS-20031 must be completed and signed by the beneficiary and the non-participating physician or supplier to transfer the beneficiary’s appeal rights.
- All appeal requests must be made in writing.