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Does Your Agency Understand How To Respond to an ADR?

Homecare Insider, July 18, 2011

Most homecare agencies are familiar with responding to a Home Health Additional Development Request (ADR). However, many are not accustomed to receiving them and often question what, exactly they should include when responding. Understanding what to include will speed up your response, which is important because your claim can be denied if you do not submit the requested information within 45 days.

When responding to an ADR, homecare providers should include a cover letter that helps justify the care delivered, summarize the patient’s needs, the skilled services provided to meet those needs, and the patient’s response/progress. Then, include specific items to support this summary and the case for payment. Those items include a plan of care and certification that is signed and dated prior to billing the final claim. Physician orders that are not included in the plan of care, signed and dated by the physician prior to billing the final claim, should also be included.

Agencies should also include documentation of services rendered, including:

  • Documentation to determine medical necessity of services billed and support the Health Insurance Prospective System (HIPPS) code
  • Time records for nursing and aide visits
  • Projected end point to daily nursing visits
  • Supporting documentation for PRN visits, including date, reason, outcome, and orders
  • Additional pertinent documentation that may support medical necessity
  • Definition of the agency’s treatment week
  • Any applicable HHABNs
  • Any additional documentation that supports your case, including local coverage determinations

Agencies should also submit an itemized supply list if supplies are billed. The list should include the quantity and cost of each item and physician orders for all supplies billed.

Agencies should remember to submit all information requested and some of this may, in fact, be outside the dates of service requested. It should be ensured that a clinical staff member reviews the information before sending it. He or she can evaluate whether all pertinent information is included and confirm that the information is complete. Do not alter or attempt to correct any documentation and retain a copy of everything you submit.

It’s important for homecare providers to remember that ADR letters are no longer mailed – the claim must be verified online. Suspended claims should always be investigated to ascertain if an ADR has been requested.