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Click ‘Get Form’ to open the Medical Review ADR Response Cover Sheet in the editor.
Begin by entering your National Provider Identifier (NPI) in the designated field. This is a crucial identifier for healthcare providers.
Next, input the Document Control Number (DCN) from the ADR letter. Remember, one form is required per DCN.
Fill in your Provider Number (PTAN) and Health Insurance Claim (HIC) Number accurately to ensure proper processing.
Provide your Provider Telephone Number and the Claim Date(s) of Service. Ensure all entries are legible.
Attach any required documentation, including a copy of the ADR letter and related physician orders. Make sure signatures are clear or include appropriate attestations.
Review all fields for completeness before submitting your response within 45 days of receiving the ADR letter to avoid automatic denial.
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Medical review is the collection of information and clinical review of medical records by Palmetto GBA to ensure that payment is made only for services that meet all Medicare coverage, coding and medical necessity requirements.
Does Palmetto GBA use change healthcare?
Change Healthcare is a clearinghouse that connects providers with insurance payers and has operations that impact the submission of Medicare claims, including claims submitted to Palmetto GBA and Railroad Medicare.
Is Palmetto GBA a Medicare administrative contractor?
announced that Palmetto GBA (Palmetto) had been awarded the contract for the combined administration of Part A and Part B Medicare fee-for-service claims in Jurisdiction 1 (J1). The states/territories included in J1 are American Samoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands.
What type of insurance is Palmetto GBA?
Palmetto GBA is the Railroad Specialty Medicare Administrative Contractor (RRB SMAC) and processes Part B claims for Railroad Retirement beneficiaries nationwide.
What does Palmetto GBA do?
Palmetto GBA is the Railroad Retirement Board Specialty Medicare Administrative Contactor (RRB SMAC). We process Part B fee-for-service claims for Railroad Medicare beneficiaries nationwide.
An additional documentation request (ADR) is generated when documentation is necessary to support a Medicare claim. This request is for medical record documentation to support payment of an item(s) or service(s) reported on the claim to ensure compliance with Medicares coverage, coding, payment and billing policies.
What is a medical review policy?
The California Department of Insurance (CDI) administers an Independent Medical Review program that enables you, the insured, to request an impartial appraisal of medical decisions within certain guidelines as specified by the law.
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