Medicare additional documentation requests (ADR) · Skilled nursing facilities
Got a Medicare ADR? You have 45 days to prove the claim.
When a Medicare contractor sends an additional documentation request, your skilled nursing facility has to show that the stay was medically necessary, skilled, and billed correctly. We build the response package, check it against the MDS and the claim, and fix what caused the request.
Call as soon as the request arrives. Records must be received by the contractor, not just mailed, within 45 days.
Who sends ADRs
Why your building received a request
An additional documentation request means a reviewer wants the medical record behind a Medicare Part A claim before or after paying it. Skilled nursing claims are pulled for review by several kinds of Medicare contractors.
Most common
Targeted Probe and Educate
Your Medicare Administrative Contractor reviews a sample of claims, usually 20 to 40 per round, with education after each round, for up to three rounds. High error rates can lead to referral for further action.
Medical review
Medicare Administrative Contractor review
Prepayment or postpayment review of specific claims, often focused on payment groups, therapy, or certification problems the contractor is seeing across facilities.
Audits
Recovery and program integrity contractors
Recovery Audit Contractors, the Supplemental Medical Review Contractor, and Unified Program Integrity Contractors can request records to find overpayments or patterns.
What reviewers look for
A complete record that proves skilled need
Most denials come from missing pieces or documentation that does not match what was billed, not from bad care. Reviewers expect to see:
- The hospital discharge or transfer summary
- Signed physician certification and recertification of the need for daily skilled care
- Admission orders, history and physical, and progress notes
- Nursing notes and therapy evaluations, orders, notes, and minutes for the billing and look-back periods
- An MDS accepted in the national repository that supports the payment group billed
Common reasons claims are denied
- Records not received by day 45
- Physician certification missing, unsigned, or late
- Notes describe the resident but not the skilled service delivered
- MDS coding not supported by the medical record
- Therapy minutes that do not match the claim
How we help
From the request letter to a complete response
Our team includes registered nurses and MDS specialists who know how skilled nursing claims are built and how reviewers read them.
- 01
Same-day request review
We confirm which claims and dates are under review, which contractor sent the request, and your exact due date.
- 02
Record gap check
We pull the full record for the billing and look-back periods and list anything missing, unsigned, or unclear before it goes out.
- 03
MDS and claim match
We compare the MDS, nursing and therapy documentation, and physician orders to the payment group and dates billed.
- 04
Organized response package
Indexed records in the order reviewers expect, with a cover letter that points to the evidence of daily skilled need.
- 05
On-time submission
We help your business office submit through the contractor’s accepted method and confirm receipt well before day 45.
- 06
Root cause and prevention
We tie findings back to Triple Check, your weekly Medicare meeting, and MDS accuracy so the same gap does not draw the next request.
Prevention
Fewer requests start before the claim goes out
The best response to an ADR is a claim that never draws one. We train your team so every Medicare claim can stand on its own.
- Triple Check training: reconcile the MDS, documentation, and claim before billing
- Medicare meeting training: skilled need, assessment dates, and documentation every week
- MDS audits that catch unsupported coding early
- An MDS nurse assigned within 48 hours if your coordinator is out
If a claim is denied
A denied claim can be appealed. The first level, a redetermination, is requested from your Medicare Administrative Contractor within 120 days of receiving the denial notice. We help you understand why it was denied and assemble the clinical documentation for the appeal, working alongside your billing team or attorney.
Related help
MDS and PDPM consulting · MDS training and leadership · Disputing survey citations
Questions
Medicare ADR questions
What is a Medicare additional documentation request (ADR)?
A request from a Medicare contractor for the medical records that support a claim you billed. The reviewer uses them to decide whether the stay was medically necessary, skilled, and billed correctly.
How long does a skilled nursing facility have to respond?
45 days. If the contractor has not received the records by then, the claim is denied automatically on day 46 for non-receipt of documentation.
What should be included in the response?
The request letter, the hospital discharge summary, physician certification and recertification, orders, nursing notes, therapy evaluations, notes, and minutes, and anything else that shows daily skilled need for the billing and look-back periods. Your contractor publishes a checklist, and we follow it.
What is Targeted Probe and Educate?
A review program where your Medicare Administrative Contractor reviews a sample of claims, usually 20 to 40, then provides education. It can repeat for up to three rounds if errors continue.
Can you help if a claim was already denied?
Yes. We review why it was denied and help assemble the documentation for a redetermination, which is generally due within 120 days of the denial notice.
Do you work with facilities outside Michigan?
Yes. We support skilled nursing facilities nationwide, remotely and onsite.
The clock is running
Received an additional documentation request?
Call now and we will review the request with you the same day.
Medicare additional documentation request
Got an ADR? You have 45 days.
- Same-day review of your request letter
- Record gap check and MDS-to-claim match
- Organized response package submitted on time