How to Build an ADR Response Packet: Cover Letter, Index, Record Order, and Attestations

Introduction

When a Medicare contractor sends an Additional Documentation Request (ADR), the reviewer who opens your response may have only a short time to find the documents that support the claim. If the key order is buried on page 140, the signature is illegible with no log, or records for three different claims are mixed together, a valid claim can be denied simply because the reviewer could not find or match what was needed.

A well-built ADR response packet solves this problem. It puts the right documents in a logical order, identifies the claim clearly, points the reviewer to the key evidence, and resolves signature issues up front. It does not change what happened, and it cannot make up for missing documentation, but it makes sure your existing documentation is seen and understood.

This article explains how to build an ADR response packet step by step: what to put first, how to write a cover letter, how to create an index, how to order records, when to include signature logs and attestations, how to submit, and how to check the packet before it goes out. It is educational and does not replace professional advice. Always follow the specific instructions in your ADR letter and your contractor's guidance.

Why Packet Organization Matters

CMS's Medicare Program Integrity Manual explains that reviewers must make determinations based on the documentation submitted and that claims are denied when requested documentation is not received or does not support the service. Organization does not change the content of the record, but it affects whether the reviewer can efficiently find and evaluate the content.

A good packet helps:

• Match documentation to the correct claim, beneficiary, and date of service.

• Highlight the documents that satisfy each coverage requirement.

• Resolve signature questions before they cause delays or denials.

• Reduce the chance that key evidence is overlooked.

• Create a clear record for any future appeal.

The Core Components of an ADR Response Packet

A typical packet for each claim includes:

1. The ADR letter or the contractor's barcode cover sheet, placed first.

2. A cover letter.

3. An index or table of contents.

4. The medical records, in a logical order.

5. Supporting documents, such as a signature log or signature attestation statements, when needed.

Each part is explained below.

Component 1: The ADR Letter or Barcode Cover Sheet

Most contractors ask providers to place a copy of the ADR letter, or the barcode cover sheet provided with the request, on top of the documentation. This allows the contractor's mailroom or imaging system to match the documents to the correct claim. MAC guidance commonly asks for one copy of the ADR letter or cover sheet per claim, with records for each claim kept separate.

For esMD submissions, providers include the information required by the esMD system, such as the documentation case ID or claim identifiers, according to the contractor's instructions. CMS has instructed contractors that their fax, mail, and esMD cover sheets should not be modified.

Practical tips:

• Never send records without the ADR letter or cover sheet.

• Use a separate copy of the letter or cover sheet for each claim.

• If you are sending records for the same claim in several transmissions, label each one, for example "Submission 1 of 3."

Component 2: The Cover Letter

A cover letter is a brief summary that introduces the packet and guides the reviewer. It is optional but very helpful. MAC guidance has noted that an outline or cover letter can serve as an index and help reviewers locate key documentation.

What to Include in a Cover Letter

• Provider name, NPI, PTAN, and address.

• Contact person, phone number, and email.

• The contractor's name and ADR reference or document control number.

• Beneficiary name and Medicare number.

• Date or dates of service and claim number.

• A short statement of the service billed.

• A brief summary of how the enclosed documentation meets the key coverage requirements, with page references.

• A list of enclosures, including any signature log or attestation statements.

• Total number of pages.

Keep It Factual and Short

The cover letter should point to the documentation, not replace it. MAC guidance has stated that the cover letter cannot be used as documentation, and that the medical record must support the contents of the cover letter. Avoid adding new clinical information that does not appear in the medical record, making arguments that the records do not support, or overstating what the documentation shows.

Sample Cover Letter Structure

• Heading with provider and contact information.

• Reference line with contractor, ADR number, beneficiary, claim number, and date of service.

• Opening sentence stating that the enclosed records are submitted in response to the ADR.

• Short paragraph summarizing the service and the key supporting documents, with page numbers. For example: physician order on page 3, face-to-face encounter note on pages 4 to 6, plan of care on pages 7 to 10, and visit notes on pages 11 to 30.

• List of enclosures.

• Closing with contact information for questions.

Component 3: The Index

An index is a simple table of contents that lists each document and the page numbers where it appears. It is especially useful for longer submissions.

How to Build an Index

1. Number every page of the packet consecutively, for example with a footer such as "Page 5 of 42."

2. List each document type with its date and page range.

3. Group related documents together, such as all visit notes.

4. Note any signature log or attestation statements and where they appear.

Example Index Entries

• ADR letter or cover sheet, page 1.

• Cover letter, page 2.

• Physician order dated March 3, pages 3 to 4.

• Face-to-face encounter note dated March 1, pages 5 to 7.

• Plan of care, certification period March 3 to May 1, pages 8 to 12.

• Visit notes, March 4 to April 28, pages 13 to 38.

• Signature log, page 39.

• Signature attestation statement for the note dated March 15, page 40.

Component 4: Record Order

There is no single required order for all services, but a logical order makes review easier. A common approach is to follow the order of the coverage requirements, often starting with orders and eligibility documents, followed by clinical documentation, and ending with supporting items.

A General Record Order

1. Orders, referrals, and prescriptions.

2. Eligibility and certification documents, such as face-to-face encounter documentation, certifications, and plans of care.

3. History and physical or initial evaluation.

4. Progress notes and visit notes for the dates of service, in chronological order.

5. Test results and reports.

6. Medication administration or treatment records.

7. Discharge summaries or reassessments, if applicable.

8. Proof of delivery, for DMEPOS.

9. Advance Beneficiary Notice, if applicable.

10. Signature log and signature attestation statements.

Tailor the Order to the Service

• Inpatient hospital stay: physician order for admission, history and physical, progress notes, procedure or operative reports, consults, discharge summary.

• Home health: face-to-face encounter documentation, certification, plan of care, OASIS assessment as applicable, visit notes, physician orders.

• Hospice: certifications of terminal illness, face-to-face encounter for recertifications as required, election statement, plan of care, interdisciplinary group notes, visit notes.

• Outpatient therapy: plan of care with certification, evaluation, treatment notes, progress reports.

• DMEPOS: standard written order, medical records from the treating practitioner supporting medical necessity, proof of delivery, and any required prior authorization documentation.

• Physician services: progress notes for the date of service, orders and results for tests, and documentation supporting the level of service.

Use your MAC's service-specific checklists and the applicable NCDs and LCDs to confirm what each claim needs.

Include Relevant Before-and-After Records

CMS's manual allows contractors to consider documentation of the beneficiary's condition before and after the service. Including relevant prior notes or later reassessments can help demonstrate medical necessity, but keep them organized and labeled.

Do Not Send the Entire Chart Unorganized

MAC guidance commonly asks providers not to send entire patient charts or multiple claims' records in the same submission without clear separation. Focus on what the ADR requests and what supports the claim.

Component 5: Signature Logs and Attestation Statements

Signature issues are a frequent cause of review delays and denials. CMS's MLN fact sheet on signature requirements explains that submitting a complete record with proper signatures helps avoid medical review delays.

Signature Log

A signature log is a typed listing of physicians and non-physician practitioners showing their names alongside their handwritten signatures or initials. CMS states that providers can create a signature log at any time and that contractors accept logs regardless of when they were created. Include a signature log whenever the packet contains signatures or initials that may be hard to read.

Signature Attestation Statement

A signature attestation statement may be used when a signature is missing from medical documentation other than an order. CMS requires the attestation to be signed and dated by the author of the medical record entry and to contain sufficient beneficiary information to identify the record. CMS will not consider attestations for unsigned orders when a signature is required, attestations not associated with a medical record entry, or attestations from someone other than the author. See the companion article on signatures for details.

Where to Place Them

Place the signature log and attestations at the end of the packet, list them in the index, and reference them in the cover letter.

Formatting and Quality Tips

• Make copies legible. Check scans and faxes for cut-off text, dark shading, or missing pages.

• Number every page.

• Keep each claim separate.

• Remove records for other patients or dates of service that are not relevant.

• Protect beneficiary privacy and follow HIPAA requirements when transmitting records.

• Use the file formats and size limits your contractor accepts for portal, CD or DVD, and esMD submissions.

• Avoid staples or bindings that interfere with scanning if submitting paper.

• Do not highlight records in ways that obscure text. If you want to point reviewers to key content, reference page numbers in the cover letter and index instead.

Submission Methods

CMS's manual states that MACs, CERT, the SMRC, and RACs accept documents via paper, fax, CD or DVD, esMD, and contractor website portals. Keep in mind:

• Portals and esMD often provide faster delivery and confirmation.

• For esMD, CMS's manual states that the esMD cloud receipt date controls for timeliness.

• For fax submissions, keep the fax confirmation.

• For mail, use a trackable method.

• For CD or DVD, follow your contractor's encryption and labeling requirements.

Always follow the instructions in your ADR letter.

Pre-Submission Quality Checklist

Before submitting, confirm:

• The ADR letter or cover sheet is on top for each claim.

• The beneficiary name, Medicare number, date of service, and claim number match the ADR.

• The cover letter is accurate and references correct page numbers.

• The index lists every document and page range.

• Every required document is included.

• Signatures are present and legible, or a signature log or attestation is included where appropriate.

• Amendments and late entries are clearly identified with date and author.

• All pages are legible and numbered.

• No records for other patients are included.

• The submission method and address match the ADR instructions.

• A complete copy of the packet is saved.

After Submission

• Confirm receipt through the portal or esMD tracking.

• Record the submission date and method in your ADR log.

• Monitor claim status and review results.

• If the claim is denied, keep the packet for your appeal. Many appeals are lost because documentation available at the time was not included in the original response, so building a complete packet the first time matters.

Building Reusable Packet Templates

Organizations that receive ADRs regularly benefit from standard templates. Templates save time, improve consistency, and reduce errors. Consider creating:

• A cover letter template with fields for provider, contractor, claim, beneficiary, service, and enclosures.

• An index template that lists the standard documents for each service line in your preferred order.

• Service-specific checklists based on NCDs, LCDs, and your MAC's guidance.

• A pre-submission quality checklist that a second reviewer signs off on.

• A standard signature log, updated regularly, that can be inserted into any packet.

• A signature attestation template that follows the language CMS provides in its manual, for use only when appropriate.

• A submission log that records the date, method, confirmation, and number of pages for each packet.

Review templates periodically, especially when coverage policies or contractor instructions change.

Special Situations

Multiple Dates of Service

For claims spanning many dates of service, such as therapy or home health, organize visit notes chronologically and consider listing each date in the index. Make sure every billed date has supporting documentation.

Large Records

For long inpatient stays or complex cases, an index is essential. Consider grouping documents by type and listing key pages, such as the admission order, the history and physical, and the discharge summary, in the cover letter.

Records From Multiple Sources

When records come from different providers, such as an ordering physician and a supplier, label each source clearly and make sure each document identifies the beneficiary and date.

Electronic Health Record Printouts

EHR printouts sometimes include unnecessary pages, such as audit headers or blank templates, and may omit key content, such as electronic signatures or addenda. Review printouts to make sure signatures, dates, and amendments appear clearly.

Responses to Third-Party ADRs

If you are an ordering or referring provider asked to submit records for another provider's claim, respond within the stated deadline, include the ADR letter or cover sheet, and send only the requested documentation.

Common Packet Mistakes

• Omitting the ADR letter or cover sheet.

• Mixing records for multiple claims.

• Sending an entire chart without organization.

• Missing orders or certifications.

• Illegible copies.

• Cover letters that contain clinical claims not supported by the record.

• No signature log for illegible signatures.

• Attestations for unsigned orders, which CMS does not accept.

• Submitting to the wrong address or fax number.

• Failing to keep a copy of the submission.

A Sample Packet Walkthrough

Consider a hypothetical outpatient therapy claim selected for review.

1. Page 1: ADR letter with barcode.

2. Page 2: Cover letter summarizing that the plan of care was certified by the physician, the evaluation supports skilled therapy, and treatment notes document progress, with page references.

3. Page 3: Index.

4. Pages 4 to 7: Initial evaluation.

5. Pages 8 to 10: Plan of care with physician certification signature and date.

6. Pages 11 to 30: Daily treatment notes for the dates of service.

7. Pages 31 to 33: Progress report.

8. Page 34: Signature log for the therapists and certifying physician.

The reviewer can quickly confirm each requirement and find the supporting documentation.

Frequently Asked Questions

Is a cover letter required?

No, but it is strongly recommended. It helps reviewers find key documents. It cannot replace the medical record.

Should I include a signature log in every packet?

Including a signature log when the packet contains signatures or initials that may be hard to read can help avoid delays. CMS accepts signature logs regardless of when they were created.

Can I highlight key parts of the record?

Use caution. It is generally better to reference page numbers in the cover letter and index than to mark the record in ways that could obscure text.

How should I handle multiple claims in one ADR?

Keep each claim's records separate, each with its own copy of the ADR letter or cover sheet, unless the contractor's instructions say otherwise.

Can I add documents after submitting?

Contractors generally review what is received by the deadline. If you realize something was omitted, contact the contractor promptly. If the claim is denied, you can submit the documentation with an appeal.

What if the ADR asks for specific documents only?

CMS's manual instructs contractors to request only the specific documents needed. Make sure every requested item is included, and add other records only when they help support the claim. Keep additional records organized and listed in the index.

Does the order of records affect the outcome?

The order itself does not change what the documentation shows. However, a logical order and a clear index help reviewers find the evidence that supports the claim, which reduces the risk that key information is overlooked.

Conclusion

An ADR response packet is your opportunity to present documentation in a way that reviewers can follow. By placing the ADR letter or cover sheet first, adding a concise and accurate cover letter, building a clear index, ordering records logically, resolving signature issues with logs and appropriate attestations, checking quality, and submitting through an accepted method, providers can make sure that valid claims are recognized as valid. Strong organization does not replace complete documentation, but it makes sure complete documentation gets the credit it deserves.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps providers create ADR packet templates, cover letters, indexes, and service-specific checklists, perform pre-submission reviews, manage signature logs and attestations, and track submissions and outcomes. If you would like help building stronger ADR response packets, please get in touch with us. We will be happy to help you with this topic.

References

• Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 3, Verifying Potential Errors and Taking Corrective Actions. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf

• Centers for Medicare & Medicaid Services. Complying with Medicare Signature Requirements (MLN905364, July 2025). https://www.cms.gov/mln905364-complying-with-medicare-signature-requirements

• Centers for Medicare & Medicaid Services. CMS Manual System, Pub. 100-20, Transmittal 2050 (esMD Cover Sheet for Unsolicited Documentation). https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2050OTN.pdf

• Centers for Medicare & Medicaid Services. CMS Manual System, Pub. 100-08, Transmittal 884 (Postpayment ADR Letter Format). https://www.cms.gov/regulations-and-guidance/guidance/transmittals/2019downloads/r884pi.pdf

• Centers for Medicare & Medicaid Services. Introducing esMD to Providers, Review Contractors, and Health Information Handlers (March 2026). https://edit.cms.gov/files/document/introducing-esmd-providers-review-contractors-health-information-handlers.pdf

• Centers for Medicare & Medicaid Services. Medicare Claim Review Programs (MLN Booklet). https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/mcrp-booklet-text-only.pdf

• U.S. Department of Health and Human Services. HIPAA Privacy Rule, Summary. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html

• Electronic Code of Federal Regulations. 42 CFR 405.930, Failure to Respond to Additional Documentation Requests. https://www.ecfr.gov/current/title-42/section-405.930

• Centers for Medicare & Medicaid Services. Original Medicare (Fee-for-Service) Appeals. https://www.cms.gov/medicare/appeals-grievances/fee-for-service