Fillable Medicare Part A Prepay Claims Additional Documentation Response (Medicare & Medicaid)

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Medicare Part A Prepay Claims Additional Documentation Response (Medicare & Medicaid)

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The Medicare Part A Prepay Claims Additional Documentation Response (Medicare & Medicaid) form is 1 page long and contains:

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Country of origin: US
File type: PDF

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Medicare Part A Prepay Claims
Additional Documentation Response (ADR) Fax Cover Sheet
Document Control Number
Patient Name Medicare ID
From:
Provider NPI Telephone
Number of faxed pages including cover sheet
1. A separate cover sheet must be submitted with each ADR letter.
2. A copy of the ADR letter must accompany the fax.
3. Do not split a record; all documentation must be submitted as one submission.
4. When faxing, please be aware of multiple sheets being fed at once. This may result in sheets not being read.
5. A medical review decision will be made based on records received in a single submission only.
6. Do not submit prepay claim ADR responses for the Recovery Auditor to the fax numbers below. Submit those items
to the Recovery Auditor, Connolly Consultants.
This cover sheet and fax numbers may only be used to respond to a Medicare prepay ADR letter.
DO NOT use for a redetermination, post pay probe, or any other correspondence.
Fax to:
Florida
(904) 361-0308
Puerto Rico
(904) 361-0409
U.S. Virgin
Islands (904)
361-0417
Privileged and Confidential
The information contained in this documentation may be confidential and is intended solely for the use of the individual or
entity to whom it is addressed. This document may contain material that is privileged or protected from disclosure under
applicable law. If you are not the intended recipient or the individual responsible for delivery to the intended recipient
please be advised that any use, dissemination, forwarding, or copying of this document is strictly prohibited; notify sender
immediately by telephone and confirm destruction of the document.
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Medicare Part A Prepay Claims Additional Documentation Response (Medicare & Medicaid)

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Completed 2 August 2020

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