CMS Issues ADR Probe Information


The Centers for Medicare and Medicaid Services (CMS) recently sent out MLN Matters number SE1524[1], which announced a “Probe and Educate” review of claims by Medicare Administrative Contractors (MACs) for episodes starting August 1, 2015 and beyond.  This CMS mandated ADR (Additional Documentation Request) probe will be focused on assessing provider’s knowledge of changes made in the 2015 Final Rule[2] regarding patient eligibility (certification/re-certification) for home health services.

Effective January 1, 2015, CMS implemented several changes, including the requirement of a face to face narrative as part of the certification of a beneficiary for Medicare home health services. Rather than relying solely on the narrative portion of a home health agency’s face-to-face encounter form to support the patient’s eligibility for Medicare funded home health services, the acute care facility or physician’s medical records are now used to substantiate and certify the patient meets the criteria. Agencies were instructed to ensure they have all needed documentation from the referral source (physician or acute care facility) to show that the patient meets eligibility requirements before billing final claims for the service provided.

This CMS mandated ADR probe will be checking to see if this updated guidance has been met. These ADR probes began on October 1, 2015, and will conclude in approximately one year.  Each provider will receive a minimum of 5 claims for pre-payment review from their Medicare Administrative Contractor. If the reviewer concludes the claim is non-compliant, they are instructed to deny payment of the claim and outline the reason for the denial in a letter to the provider. The provider may also be offered a one on one phone call for purpose of further education on why the claim was non-compliant and what the agency needs to do to ensure compliance.  In the event of moderate to major concerns on the initial review, CMS may instruct the MAC to review 5 additional claims after the education for compliance and education.

Although this probe is initiated to check for compliance with eligibility requirements, the reviewer can and may deny the claim for ANY noted non-compliance issues such as not meeting the definitions of skilled or reasonable and necessary care, among other reasons. The guidance for skilled care definitions and reasonable and necessary care is found in Medicare Benefit Policy Manual, Chapter 7 Home Health.[3]

Should you receive a denial following review of an ADR, remember that you have the right to appeal this denial. However, if the appeal is not filed according to prescribed timelines, you forfeit your ability to appeal the claim denial. Information about the appeals process can be found here:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c29.pdf

Please also note that if a requested ADR is not submitted within the 45 day time frame, it is automatically denied. In order to ensure that you have plenty of time to collect all needed documentation, be sure to check Axxess DDE[4] or other DDE ( Direct Data Entry) systems that you use for any ADR requests, on a daily basis. This is a much more efficient way to realize you have an ADR, as this information is noted in the DDE system before you receive a hard copy letter via the postal service. Once you have your hard copy letter, you will have written instruction on how to submit the requested documentation to the MAC as requested.

While time consuming, ADRs should be completed timely and thoroughly to prevent cash flow interruptions. For further questions regarding this review probe, or the process of submitting requested documentation, contact your MAC.


[1] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1524.pdf

[2] https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-Notices-Items/CMS-1611-F.html

[3] https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf

[4] http://www.axxess.com/rcm/axxess_dde

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