What do you do when Medicare sends an ADR on a home health claim in 2026?

CMS says an ADR "is generated when documentation is necessary to support a Medicare claim." The reviewer can't decide your claim from the claim alone, so it asks for the records behind it.

The letter goes to the address Medicare has on file, so keep your Medical Review Correspondence Address current in PECOS, the Medicare enrollment system. The request often shows in the claims system first. At CGS, for example, the claim stops at status S B6001, reason code 39700, and you answer in the myCGS portal; your own MAC's ADR page gives its codes and portal.

Four MAC (Medicare Administrative Contractor) jurisdictions handle home health and hospice: Palmetto GBA in JM, CGS in J15, and National Government Services in J6 and JK.

Your MAC, the Recovery Audit Contractor (Cotiviti GOV Services for home health nationwide), the Supplemental Medical Review Contractor (Noridian) and CERT, which samples claims at random to measure improper payments, all give you 45 calendar days. A UPIC (Unified Program Integrity Contractor), which looks for suspected fraud, waste and abuse, gives you 30.

A contractor may accept late records for good cause, "such as natural disasters, interruptions in business practices, or other extenuating circumstances." If you need more time, ask before the due date and write down who agreed.

Late or missing records mean the claim can be denied as not reasonable and necessary. On a postpayment review, the money you were already paid becomes an overpayment. A MAC may choose to reopen if the records arrive within a reasonable time, "generally 15 calendar days after the denial date"; a RAC won't.

If your agency is in 100% postpayment review under review choice, every claim gets a request. The California and six-state chapters explain how agencies land there.

MACs, CERT, the SMRC and RACs must accept paper, fax, CD or DVD, the contractor's portal, and esMD (Electronic Submission of Medical Documentation), where the day your file lands counts as the day received, or the next business day if it lands after hours. UPICs can use a secure file service called Kiteworks. For mail in a hurry, CGS suggests USPS overnight over FedEx or UPS.

Put a copy of the ADR on top, which CMS calls "best practice," and keep each claim's records separate and unstapled, as CGS asks. A cover letter can point to key dates, but CGS says it "cannot be used as documentation."

CGS publishes its nurse reviewers' order: the technical pieces first (OASIS submission, certification and orders, the face-to-face encounter), then homebound status, skilled need and medical necessity. Every MAC applies the same Benefit Policy Manual.

Homebound status takes two tests: the patient needs help, a device or special transport to leave home, or leaving is medically contraindicated; and there's a normal inability to leave, with leaving taking "a considerable and taxing effort." The manual says reviewers typically need the clinical picture over time: diagnosis, course, and what the patient can and can't do.

The face-to-face encounter falls no more than 90 days before or 30 days after the start of care, relates to the primary reason for home health, and is done by an allowed practitioner. "The actual clinical note" must be in the certifying practitioner's chart, or the hospital's or post-acute facility's if the patient came straight from there. Your plan of care and assessment can support homebound status and skilled need once the practitioner signs and dates them into that record and other entries there corroborate them; they can't stand in for the encounter.

A physician or allowed practitioner who meets the certification requirements signs and dates the plan of care before you submit the final claim for each 30-day period. Verbal orders carry the signature and date received from the nurse or therapist responsible, and the practitioner's countersignature before you bill.

For a missing or unreadable signature, the reviewer can give you 20 calendar days to send an attestation from the entry's author. It can't "backdate" a plan of care, the manual says; our reading is that one signed after the final claim stays a problem.

Targeted Probe and Educate (TPE) means your MAC is sampling your claims because your data stood out. A round "typically" covers 20 to 40 claims, followed by a results letter, an offer of one-on-one education and at least 45 days before new claims are picked. A low error rate releases you for a year; a high one after three rounds goes to CMS, which may order 100% prepayment review, extrapolation (applying your error rate to more claims) or referral for revocation of billing privileges.

Medicare has five appeal levels, and each notice is presumed received five days after its date.

Send every record by level two: CMS says documentation the QIC never saw "may be excluded from consideration at subsequent levels of appeal" without good cause.

On a postpayment denial, watch the calendar from the demand letter:

• Day 30: file your redetermination by now and Medicare won't start taking the money back while it's decided. File later and recoupment stops, but what was already taken stays with Medicare until the redetermination is decided.
• Day 31: interest starts, appeal or not.
• Day 41: recoupment (Medicare taking it from your future payments) starts if you haven't appealed.

Lose the redetermination and recoupment can resume 60 days later; a timely, valid reconsideration request stops it again.

The internal dates in this plan are our suggestions; CMS sets only the response and appeal deadlines.

1. Log every request the day it lands. Patient, claim, who sent it, due date, proof of receipt, decision, dollars and any appeal dates.
2. Build the packet in a set order. CGS's is a good start: the ADR letter and contact form, face-to-face documentation, plan of care with certification, interim or verbal orders, OASIS, then nursing, therapy, social work and aide notes. Check your own MAC's list.
3. Have a clinician read it before it goes. Check it against the reviewer's list and chase gaps while there's time.
4. Sort denials by reason every quarter. If thin face-to-face notes keep coming from one referral source, take it up with that source.

Enzo is a home health EHR. Enzo Intake checks each referral package for face-to-face documentation the moment it arrives. Enzo QA reviews every chart before submission, including Plan of Care alignment, and explains what needs attention and why. Your team makes the call.

The face-to-face note is in the doctor's chart, not ours. Is that our problem?

Yes. The manual says your agency "must be able to provide, upon request, the supporting documentation" for eligibility. Get a copy of the note at admission.

Does an ADR mean we're under investigation?

Not by itself. CERT picks claims at random, and MAC, RAC and SMRC reviews follow data and assigned topics. A UPIC is different: CMS's manual says its primary goal is "to identify cases of suspected fraud, waste and abuse."