Medical Review: Additional Documentation Requests (ADRs)

If you receive a Medical Review Additional Documentation Request (ADR) for one or more claims that you have submitted to Railroad Medicare for payment, it is important that you comply with the following instructions.

1. Provide the documents listed on the ADR and any related physician’s orders. Make sure the physician's signature is legible or include an attestation of signature. 
    
2. Include a copy of the ADR letter with your documents. If you do not have a copy of the ADR letter, include a completed Medical Review ADR Response Cover Sheet (PDF). Use one ADR Response Cover Sheet for each ADR letter/claim.
   
   To find the cover sheet, please visit our Railroad Medicare Form Finder page. From there, select “Medical Review,” then “Submit additional documentation.” Next, choose “This submission is for a medical review additional documentation request (ADR).”  Then, answer the question “Is your response late (over 45 days from the date of the ADR?” A link to the correct form will be presented to you based on your answers.
    
3. When returning ADR responses for multiple letters, be sure to pair each ADR letter or Medical Review ADR Response Cover Sheet with the corresponding documentation. Pairing these documents ensures the documentation you return for each request letter is correct for each date of service requested.
    
4. Return your documents using one of the following methods. Do not submit by more than one method as a duplicate response slows down the documentation review process.
    
   • Upload your ADR response through eServices, our free, self-service portal located on the Palmetto GBA website at www.PalmettoGBA.com/eServices. eServices lets you upload your ADR response electronically, eliminating the need to fax or mail documents and packages. To participate, you must have an EDI agreement on file with Railroad Medicare.  When you upload a document, you will receive a message when the form is submitted and another message with the Document Control Number (DCN) when the form has started processing. You can use the DCN to look up form processing status and view your submitted forms.
      
   • Submit your ADR response via the esMD (Electronic Submission of Medical Documentation) mechanism.  For more information about esMD, please see the CMS website.
      
   • Fax your ADR responses to (803) 264–8832
      
   • Mail your ADR response to: 
     Palmetto GBA Railroad Medicare
     Medical Review
     P.O. Box 10066
     Augusta, GA 30999
      
5. Return your ADR response to Palmetto GBA within 45 days of the date on the ADR letter. The claim will automatically deny by the 46th day if a response has not been received.
    
6. Once ADR responses are received, CMS requires Palmetto GBA to complete medical review of the documentation within 30 days for prepayment reviews or within 60 days for postpayment reviews. Do not resubmit ADR responses to Palmetto GBA.
    
7. Do not submit replacement/duplicate claims for the ones pending in medical review. The submission of replacement/duplicate claims will result in claim denials and will prolong the medical review process.
    
8. When the claim is finalized, the claim will receive a status of paid, denied or rejected.
    
   • If you disagree with a denial or payment, you can request a redetermination. Information on requesting a redetermination can be found in Railroad Medicare Appeals.
      
   • If the claim was rejected as unprocessable with remittance message MA130, you must submit a new corrected claim

Palmetto GBA has developed several checklists that will assist you in responding to medical record documentation requests. See the Medical Review Checklists page. 

Railroad Medicare: Important Reminder 
Keep your address updated to avoid delays in receiving your ADRs. You must notify your local A/B MAC within 30 days of an address change. Once you submit the changes to your local A/B MAC and receive confirmation of completion, you can send your changes to Railroad Medicare in writing to: