General

1. Question: Is a copy of the Additional Documentation Request (ADR) letter required with the provider’s ADR response?

Answer: Submitting a copy of the ADR is listed on the ADR document issued to the providers as information to submit. If the provider does not have a copy of the ADR, they can place a cover sheet with the claim number, as well as the date of service (DOS) with Part A Medical Review (MR).
 

2. Question: Can a provider submit a response for a past-due ADR?

Answer: The Centers for Medicare & Medicaid Services (CMS) contractors may accept late documentation if the provider can demonstrate good cause (natural disaster, business interruptions, extenuating circumstances, etc.). Providers typically have a maximum 120 days to submit their ADR response to MR from the denial date for records not received timely. Submit the late response to the department that initially requested the documentation, not to the Appeals Department. However, this is not the recommended approach, as providers should typically respond to ADR requests within 45 days.
 

3. Question: Should the providers complete the provider contact box for each ADR response?

Answer: Yes, the provider should provide their point of contact information with each ADR response. This is stated on the ADR letter sent to the provider. The MR team uses the updated contact information to reach out to the contact person listed on the form. This will occur during the review process if documentation is incomplete or clarification is needed. However, if the contact information needs to be changed/updated, please call the PCC to have the information reviewed and send it to MR for updates. It is a best practice to provide first and second choices, should the initial contact be out of the office when MR attempts to reach you.
 

4. Question: Can the provider be given the assigned medical reviewers’ information?

Answer: Claims are randomly assigned to our medical reviewers. While we have dedicated reviewers for each line of business, we cannot inform providers in advance who will review their claim. If documentation is incomplete or clarification is needed, the assigned reviewer will contact the point of contact person on file to resolve the issue.
 

5. Question: Who do I contact after receiving the Targeted Probe and Educate (TPE) Final Results?

Answer: The Senior Provider Education Consultant for Medicare Part A will contact you within two weeks of receiving your TPE Final Results Letter. If you are moving on to a subsequent round, you’ll have 45–56 days before it begins, starting from the date of your education session. The Senior Provider Education Consultant will make a maximum of three attempts to contact the designated individual(s) for your office. If these attempts are unsuccessful, it will be your responsibility to initiate contact with the Senior Provider Education Consultant regarding your Medicare Part A education session. If this occurs, you will move on to a subsequent round and the 45–56-day period will begin on the date of the third missed attempt.
 

6. Question: When will the provider need to submit their appeal once their claims have been denied due to the TPE audit?

Answer: Providers may submit an appeal once they receive the official Claim Determination. Appeals must be submitted in writing within 120 days from the date on the Claim Determination. Providers should not wait until they receive the results letter, as it may be past the 120-day timeframe.

7. Question: Do incarceration periods include halfway houses?

Answer: Starting January 1, 2025, patients in custody no longer include patients who are:

• Released to the community pending trial (including those released on bail)
• On parole
• On probation
• On home detention
• Required to live in a halfway house or other community-based transitional facility
   

8. Question: My claims have been denied due to no records received; however, medical records were sent 30 days prior to the due date.

Answer: The provider will need to contact the PCC to have the medical records escalated to MR for review and possible reopening.
 

9. Question: Why are we getting non-response communications for ADRs with due dates 90 days from the letter date? I understand that the standard is 45 days, but the letter gives a due date 90 days from the ADR letter date.

Answer: Due to recent hurricanes and natural disasters, ADR letters had a due date of 90 days.
 

10. Question: Do we need to send the medical records with each level of appeal, or does the previous level send those records to the next level for us?

Answer: Yes, make sure you include the records with each level.
 

11. Question: Are the Reconsideration results added to eServices as well for us to download?

Answer: Yes, if a Reconsideration has been submitted, the status will be provided in eServices.
 

12. Question: Does an appeal have to be signed by the ordering physician, or can any physician sign the appeal?

Answer: It does not need to be signed by the ordering physician.
 

13. Question: Can you tell us again where to find the appeal details on the claim?

Answer: The remarks section of the claim.
 

14. Question: If the provider cannot provide the required documentation when CERT audits a Medicare Part A claim, when does recoupment for any overpayment begin?

Answer: Appealing an Overpayment Subject to Limitation on Recoupment. If you do not request redetermination or make payment in full by the 39th day:

• A withholding is initiated on the Remittance Advice (RA) dated the 40th day from the initial demand letter interest accrues on the money owed from the date of the initial demand letter.
• The withholding amount will appear in the 935-withholding section of the RA

Last Reviewed: 09/10/2025