A Medicare ADR checklist lists everything a complete response to an additional documentation request needs: a copy of the ADR letter on top, the orders, the signed notes for each date of service, any signature log or attestation, and a short cover letter. Each item is checked against the claim and the dates the letter names before it is sent.
What a Medicare ADR letter asks for
A Medicare additional documentation request (ADR) is a letter from a Medicare review contractor asking a provider for the records that support a specific claim. It names the beneficiary, the claim, the dates of service under review and the documents the contractor needs, and it states the date the response is due.
The CMS Additional Documentation Request page says an ADR "is generated when documentation is necessary to support a Medicare claim" and is sent to the practice address on file with Medicare. CMS asks providers to keep the "Medical Review Correspondence Address" current in PECOS so the letter reaches the right desk.
The Medicare Program Integrity Manual, chapter 3 (Rev. 13821, issued 06-09-26) sets the letter's shape. Section 3.2.3.1 says contractors "shall specify in the ADR only those individual pieces of documentation needed to make a determination." Section 3.2.3.4 lists the elements a post-payment ADR from a MAC, RAC, CERT or SMRC contractor must include: an introductory paragraph naming CMS, the review program and the rules that apply, the reason for selection, the action to take, the reply date, the consequences of not replying, and instructions.
Read the "Action" and "Instructions" parts twice. They are the contractor's own list of what to send, and the checklist below should follow it.
The Medicare ADR checklist, item by item
The Medicare ADR checklist below turns the letter into a set of items to gather and tick off, so nothing requested is left out and nothing unrelated is added. Work through it with the ADR letter open, because the letter's own list always takes priority over a general checklist.
The table is a working example for a fictional claim: beneficiary Ruth Calloway, claim number 21-2026-188-04521-00, date of service 04/09/2026. All values are made up.
| Item | Where to find it | Done |
|---|---|---|
| Copy of the ADR letter, as page 1 | The letter itself, or the eMDR if it came through esMD | ☐ |
| Cover letter: provider name, NPI, claim number, date of service, page count, contact | Written for this response | ☐ |
| Order or referral for the service | EHR orders, referral letters, signed requisitions | ☐ |
| Signed and dated note for each date of service | EHR encounter notes, procedure notes | ☐ |
| Supporting results or reports the note relies on | Lab, imaging and test reports in the chart | ☐ |
| Earlier records that show why the service was needed, if relevant | Prior visit notes, history | ☐ |
| Signature log for initials or illegible signatures | Practice compliance file | ☐ |
| Signature attestation, if a signature is missing | Signed by the note's author | ☐ |
| Index of the pages sent, in order | Built from the pages above | ☐ |
| Proof of submission: esMD receipt, portal confirmation, fax log or tracking number | Kept in the practice's records | ☐ |
Three items need a word of explanation. CMS calls attaching a copy of the ADR letter as the first page "best practice" on its ADR page, because it lets the contractor match the response to the request. The same page notes that the documentation may include records from before the billing period under review.
Signature logs and attestations follow PIM section 3.3.2.4. A signature log lists the typed or printed name for initials or an illegible signature. An attestation must be signed and dated by the author of the medical record entry and must identify the beneficiary. The manual says contractors shall not consider an attestation with no associated record entry, or one from someone other than the author.
How long do you have to answer a Medicare ADR?
Most Medicare ADRs must be answered within 45 calendar days, and the due date printed on the letter is the one to plan around. Requests from a Unified Program Integrity Contractor (UPIC) allow 30 calendar days. If the records do not arrive in time, the contractor can deny the claim.
The deadlines come from regulation:
- 45 calendar days, post-payment review by a MAC, RAC, SMRC or CERT contractor: 42 CFR 405.929 on the eCFR, paragraph (b)(1), repeated in PIM section 3.2.3.2(B).
- 45 calendar days, prepayment review: 42 CFR 405.903 on the eCFR, paragraph (b)(1), repeated in PIM section 3.2.3.2(A).
- 30 calendar days for a UPIC request: 42 CFR 405.929(c) and 405.903(c).
- Late records: both sections let a contractor accept documentation after the deadline "for good cause", such as natural disasters or interruptions in business practices.
- No response: 42 CFR 405.930 on the eCFR gives the contractor "authority to deny the claim".
If you need more time, the CMS ADR page encourages providers to work with their MAC. Do not assume an extension until the contractor confirms it. When a signature attestation is requested later in the review, PIM section 3.3.2.4 gives the provider 20 calendar days to send it.
A denied claim is not the end of the road, but it moves the claim into appeals, which is a different process covered in the revenue cycle automation category.
Medicare ADR responses that get denied
Medicare ADR responses get denied most often for problems a final check would have caught: missing or unacceptable signatures, records for the wrong date of service, and pages the reviewer cannot read. Each one is a documentation gap, not a coverage question.
Missing signatures. A note without its author's signature may not count. PIM section 3.3.2.4 says stamped signatures "are not typically acceptable", apart from a narrow exception for an author with a disability. Include a signature log or attestation where the manual allows one.
Wrong date of service. The response includes a visit from 04/02/2026 when the ADR asked about 04/09/2026. The reviewer finds no support for the date under review.
Illegible pages. Faint faxes, cut-off margins and handwritten notes nobody can read leave the reviewer without evidence. Print EHR notes directly instead of faxing copies of copies.
Late addenda. PIM section 3.3.2.5 says the date and author of any amendment or delayed entry should be identifiable and the change clearly marked. An unmarked change made after the ADR arrived invites questions.
Should you send the whole chart with a Medicare ADR response?
No. Send what the ADR asks for, for the dates of service under review, plus earlier records only when they show why the service was needed. A whole chart buries the relevant pages, slows the review, and discloses more patient information than the request needs.
The HIPAA Privacy Rule's minimum necessary standard, in 45 CFR 164.502 on the eCFR, paragraph (b), says a covered entity must make reasonable efforts to limit protected health information to the minimum necessary for the purpose. The ADR's own list is the best guide to that minimum.
Psychotherapy notes are a special case. PIM section 3.3.2.6 says contractors shall never request them, and that a provider who holds them is responsible for extracting the information that supports the claim.
Checking each page's date and patient name against the letter before sending is tedious work. Schema Care reads encounter dates, problem lists, allergies and vitals from medical records and flags fields it is unsure of for a person to confirm, as the list of supported documents explains. For what to look for in a tool built for this kind of reading, see the guide to medical record review software. Commercial plans run their own reviews on different rules, explained in the guide to types of payer records audits.