Reading an ADR Letter: Claim Under Review, Documents Required, and Common Misunderstandings

Introduction

A Medicare Additional Documentation Request (ADR) letter can look intimidating. It is often full of identifiers, regulatory citations, and instructions. But every section of an ADR letter serves a purpose, and reading it carefully is the first step toward a successful response. Many ADR denials happen not because the documentation did not exist, but because the provider misread what was requested, sent records for the wrong claim, missed the due date, or misunderstood what the letter meant.

CMS requires ADR letters to contain specific elements, and postpayment ADRs follow a unified format so that letters from different contractors look more consistent. Understanding that structure makes it easier to find what matters.

This article walks through an ADR letter section by section, explains how to identify the claim under review and the documents required, highlights the most common misunderstandings, and offers a practical checklist for reading every ADR. It is educational and does not replace professional advice.

Why ADR Letters Look the Way They Do

CMS's Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.4, requires each ADR to include specific elements:

• A. Introduction, identifying CMS, the program, and applicable laws.

• B. Reason for selection.

• C. Required action.

• D. Due date.

• E. Consequences of failing to respond.

• F. Instructions.

• G. Submission methods.

• H. Contact information.

• I. Attachments or supplementary information.

CMS also requires postpayment ADRs to follow a unified format in a specific order, and CMS has standardized the postpayment ADR letter format used by the SMRC, DME MACs, RACs, and the CERT contractor to make letters more recognizable and understandable. CMS's manual further requires prepayment ADRs to carry the applicable Office of Management and Budget (OMB) control number and directs that ADRs request only the specific documents needed.

Section by Section: How to Read an ADR Letter

The Header: Who Sent It and When

Start with the basics:

• Contractor name. Is it your MAC, a RAC, the SMRC, CERT, or a UPIC? Each has different deadlines and procedures.

• Letter date. This date is usually the starting point for the response deadline.

• Letter or reference number. Use this in all communication and on your submission.

• Barcode or document control number. Many ADRs include a barcode or cover sheet that must accompany your response.

Verify that the contractor is legitimate by comparing the name and contact information with CMS's Review Contractor Directory and your MAC's website.

The Introduction: The Legal Basis

The introduction explains why Medicare can request documentation. CMS's manual directs contractors to cite Sections 1815(a), 1833(e), and 1862(a)(1)(A) of the Social Security Act. In plain terms, Medicare does not pay unless the provider supplies the information necessary to show that payment is due and that the service was reasonable and necessary. The introduction may also identify the review program, such as TPE, a RAC topic, or an SMRC project.

The Claim Under Review

This section, or an attached claim list, identifies exactly which claims are under review. Look for:

• Beneficiary name and Medicare Beneficiary Identifier (MBI).

• Claim number, such as the Internal Control Number (ICN) or Document Control Number (DCN).

• Dates of service.

• Procedure or HCPCS codes, or item descriptions.

• Billed or paid amounts.

• Your NPI and PTAN.

Compare each claim with your own records to confirm that you are pulling documentation for the right patient, service, and date.

The Reason for Selection

The reason for selection explains why the claim was chosen. Examples include:

• A Targeted Probe and Educate review of a specific service.

• An approved RAC topic, such as a particular DRG or service.

• An SMRC national project.

• A CERT random sample.

• A MAC service-specific review based on data analysis.

• A UPIC investigation.

This section tells you what the reviewer will focus on. If the letter says the review concerns medical necessity of a particular service, make sure your documentation clearly addresses the coverage criteria for that service.

The Required Action and Documents Requested

This is the heart of the letter. It lists the documents the reviewer needs. Common items include:

• Physician orders or referrals.

• Progress notes for the dates of service.

• Certifications and recertifications.

• Plans of care.

• Face-to-face encounter documentation.

• Test results.

• Proof of delivery for DMEPOS.

• Signature logs or attestations.

• Advance Beneficiary Notices.

CMS's manual directs contractors to request only the specific documents needed. Read the list carefully and make sure you include every item. If a listed document does not exist, note that fact rather than ignoring it.

CMS's manual also allows contractors to collect documentation related to the beneficiary's condition before and after the service to get a more complete clinical picture, so the letter may request records outside the date of service.

The Due Date

The letter states when documentation must be received. CMS's guidance provides 45 calendar days for MAC, SMRC, and RAC requests and 30 calendar days for UPIC requests. Contractor guidance commonly explains that the timeframe begins on the date of the letter. Calendar the due date immediately.

Consequences of Not Responding

The letter will explain that if documentation is not received by the due date, the claim will be denied. For postpayment reviews, a denial creates an overpayment that the MAC will recover. CMS's manual directs MACs to deny non-response claims using group code CO, CARC 50, and RARC M127.

Instructions and Submission Methods

This section explains how to submit. CMS's guidance lists submission methods including mail, esMD, the MAC's provider portal, fax, and CD, DVD, or USB. The letter may specify:

• Where to send documentation.

• Whether to include the ADR letter or a barcode cover sheet as the first page.

• How to separate documentation for multiple claims.

• File formats and size limits for electronic submissions.

CMS advises providers to attach a copy of the ADR letter as the first page of their documentation so it is matched to the correct patient and claim.

Contact Information

Use the contact information for questions about the request, the documents needed, submission, or additional time. Keep notes of every contact.

Attachments

Attachments may include a claim list, a barcode cover sheet, a list of requested documents, or educational materials. Read all of them.

Electronic ADRs (eMDR)

Providers registered for electronic medical documentation requests (eMDR) through esMD may receive ADR letters electronically through their Health Information Handler. CMS has added a "Requested Documents for an ADR" list to eMDRs, which can help providers see exactly what is needed. The content and requirements are the same as paper letters, so read eMDRs with the same care.

Common Misunderstandings About ADR Letters

"The Deadline Starts When We Receive the Letter"

Contractor guidance commonly explains that the response period begins on the date of the letter. Mail delays and slow internal routing can significantly reduce the time available.

"An ADR Means We Are Suspected of Fraud"

Not necessarily. Many ADRs result from routine reviews, random CERT samples, national SMRC projects, approved RAC topics, or TPE. UPIC ADRs may relate to potential fraud, waste, or abuse investigations, so they deserve extra attention, but an ADR itself is not an accusation.

"We Should Send the Entire Medical Record"

Sending a whole chart without organization can make it harder for reviewers to find what they need. CMS directs contractors to request specific documents, and contractor guidance commonly asks providers not to send entire charts unorganized. Send what is requested and what supports the claim, clearly organized.

"We Only Need to Send the Documents on the List"

The list is the minimum. If other documentation is necessary to support medical necessity or other coverage requirements, such as prior notes that establish the patient's condition, include it in an organized way.

"A Cover Letter Can Explain Missing Documentation"

A cover letter can guide the reviewer, but it is not a substitute for the medical record. Contractor guidance has stated that the cover letter cannot be used as documentation and that the record must support the cover letter's contents.

"Supplier or Billing Forms Prove Medical Necessity"

CMS's manual states that certificates of medical necessity, supplier statements, and physician attestations by themselves do not sufficiently document medical necessity. The treating practitioner's medical record must support the claim.

"The Ordering Physician Is Responsible for Sending Records"

The billing provider is ultimately responsible for submitting the requested documentation. Even when the contractor sends a third-party ADR, the billing provider's payment is at risk.

"If the Claim Is Denied, We Can Bill the Patient"

Denials for non-response or insufficient documentation are generally assigned group code CO, meaning the provider is responsible and the beneficiary may not be billed, unless a valid Advance Beneficiary Notice or other rule shifts liability.

"A TPE ADR Is Just Education"

TPE includes education, but each ADR is a real review. Denied claims are not paid or are recovered, and continued high error rates after three rounds can lead to referral to CMS for further action.

"A RAC ADR Has No Limit"

CMS sets limits on the number of ADRs RACs can issue to a provider within specific timeframes, based on factors such as provider type and claim volume. RAC ADR letters often state the provider's ADR limit. Understanding these limits helps providers anticipate workload, though CMS-required RAC reviews may fall outside established limits.

"We Can Respond After the Due Date Without Consequences"

Late documentation may be accepted only in limited circumstances, such as good cause or a timely late documentation reopening. Plan to respond well before the due date.

Reading ADR Letters From Different Contractors

While CMS has standardized many elements, ADR letters from different contractors emphasize different things. Knowing what to look for helps.

MAC Letters

MAC ADRs often relate to TPE, service-specific reviews, or prepayment edits. Look for the specific edit or review topic, the TPE round if applicable, and references to local coverage determinations or checklists. Prepayment MAC ADRs may also appear in your claims processing system, such as the Fiscal Intermediary Standard System for Part A, so monitor claim status as well as mail.

RAC Letters

RAC ADRs identify the approved review topic and often state your ADR limit. Look for the issue name, the description of why the claim was selected, and any statement that the RAC has good cause to reopen the claim. RAC reviews are postpayment, so denials become overpayments recovered by your MAC.

SMRC Letters

SMRC ADRs usually describe a national review project, such as a specific service or item with a high improper payment rate. Look for the project description and the specific codes under review.

CERT Letters

CERT letters come from the CERT contractor, not your MAC, and relate to a random sample used to measure the national improper payment rate. Look for the CERT claim identification number and cover sheet instructions. CERT has its own timeframe, with no documentation within 75 days counted as an error.

UPIC Letters

UPIC ADRs allow 30 days and may relate to investigations of potential fraud, waste, or abuse. Read these letters especially carefully, note whether the request covers a large number of claims or a long period, and consider involving your compliance officer and legal counsel.

Questions to Ask After Reading the Letter

After reading the ADR, answer these questions before starting to gather records:

• Which contractor sent the letter, and is it legitimate?

• What is the exact due date, counted from the letter date?

• Which claims, beneficiaries, and dates of service are under review?

• What is the reason for selection, and what coverage rules apply?

• Which documents are specifically requested?

• What other documents are needed to support the claim?

• Do we need records from another provider?

• Are there any signature issues we can resolve up front?

• How must we submit, and what must be included as the first page?

• Who on our team is responsible, and what is our internal target date?

• Does this request suggest a broader risk that compliance leadership should know about?

Understanding the Tone and Legal Language

ADR letters are written to meet legal and regulatory requirements, so they often cite statutes and regulations and describe consequences in direct language. This tone is standard and does not by itself indicate that the contractor suspects wrongdoing. Focus on the practical requirements: what is needed, by when, and how to submit.

A Practical Checklist for Reading Every ADR

1. Identify the contractor and verify it.

2. Note the letter date and calculate the due date.

3. Record the reference number and barcode.

4. List every claim, beneficiary, date of service, and service under review.

5. Confirm the claims match your records.

6. Read the reason for selection and identify the applicable coverage requirements.

7. List every document requested.

8. Identify any additional documentation needed to support the claim.

9. Identify any third-party records you must request.

10. Read submission instructions, including cover sheet and format requirements.

11. Note contact information.

12. Review all attachments.

13. Log the ADR and assign responsibility.

14. Set internal target dates and reminders.

A Hypothetical Example

A cardiology practice receives a letter from its MAC. The header shows the MAC's name and a letter date of March 2. The claim list identifies three beneficiaries with echocardiograms performed in January. The reason for selection explains that the claims are part of a TPE review of echocardiography. The required documents include the ordering physician's order or intent to order, the clinical notes supporting medical necessity, the signed interpretation report, and a signature log if signatures are illegible. The due date is 45 calendar days from the letter date. The instructions ask the practice to include the ADR letter as the first page of each response and list the portal, esMD, fax, and mail as options.

The practice logs the ADR on March 4, calculates the April 16 due date, sets an internal target of April 1, pulls the records, notices that one interpretation report has an illegible signature, adds a signature log, and submits through the portal on March 28 with the ADR letter on top of each claim's records. All three claims are approved.

Common Identifiers on an ADR Letter

• MBI: the Medicare Beneficiary Identifier for the patient.

• ICN or DCN: the claim's control number in Medicare's claims processing system.

• NPI: your National Provider Identifier.

• PTAN: your Provider Transaction Access Number assigned by your MAC.

• Letter ID or case ID: the contractor's reference number for the request.

Frequently Asked Questions

What is the most important part of an ADR letter?

The claim list, the documents requested, and the due date are critical. The reason for selection is also important because it tells you what the reviewer will focus on.

How do I know the letter is legitimate?

Compare the contractor name and contact information with CMS's Review Contractor Directory and your MAC's website. Contact your MAC if you are unsure.

What should I do if the letter requests a document that does not exist?

Do not ignore it. Submit everything that does exist, and consider noting that the requested document is not available. Evaluate whether other documentation meets the requirement.

Can I call the contractor with questions?

Yes. Use the contact information in the letter, and keep notes of every contact.

Do electronic ADRs have the same requirements?

Yes. eMDRs delivered through esMD carry the same requirements and deadlines as paper ADRs.

What if the letter lists claims I do not recognize?

Check your billing records using the claim numbers, beneficiary identifiers, and dates of service. If a claim was billed under a different location, NPI, or PTAN, route the request to the right team. If you still cannot identify the claim, contact the contractor promptly.

Should I respond to each claim separately?

Generally yes. Keep each claim's documentation separate, with its own copy of the ADR letter or cover sheet, unless the contractor's instructions say otherwise. This helps the contractor match records to the correct claim.

What if the ADR covers many claims?

Large requests require planning. Prioritize by due date, assign staff to specific claims, track progress daily, and request third-party records immediately. If the volume creates a genuine hardship, contact the contractor early to discuss options.

Can I submit records before the due date for some claims and later for others?

Submitting complete responses as soon as each claim is ready can reduce risk. Make sure each submission is clearly labeled and includes the ADR letter or cover sheet.

What if the ADR seems to request the wrong service?

Review your records carefully. If the letter appears to contain an error, contact the contractor to clarify, document the conversation, and still respond by the due date with the best available documentation.

Conclusion

An ADR letter tells you everything you need to respond successfully: who is asking, which claims are under review, why they were selected, what documents are needed, when they are due, and how to submit them. Reading every section carefully, confirming the claims, identifying all required and supporting documents, calculating the due date from the letter date, and avoiding common misunderstandings can prevent many denials. A consistent reading checklist and logging process help make sure nothing is missed.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps providers interpret ADR letters, identify required documentation, build ADR intake checklists, manage deadlines, assemble organized responses, and train staff to recognize and route ADRs quickly. If you have received an ADR and want help understanding what is being asked, please get in touch with us. We will be happy to help you with this topic.

References

• Centers for Medicare & Medicaid Services. Additional Documentation Request. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-education/additional-documentation-request

• 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. 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. Review Contractor Directory, Interactive Map. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/review-contractor-directory-interactive-map

• Centers for Medicare & Medicaid Services. MLN Matters MM11003, Electronic Medical Documentation Requests (eMDR) Registration (Revised March 20, 2024). https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/mm11003.pdf

• Centers for Medicare & Medicaid Services. Recovery Audit Program, Additional Documentation Limits. https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program

• Centers for Medicare & Medicaid Services. Targeted Probe and Educate. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/targeted-probe-educate-tpe

• 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. Social Security Administration. Social Security Act, Section 1862. https://www.ssa.gov/OP_Home/ssact/title18/1862.htm

• Electronic Code of Federal Regulations. 42 CFR 405.930, Failure to Respond to Additional Documentation Requests. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/subject-group-ECFRba80b2c5e3f1227/section-405.930