An ADR lands on Tuesday. You have 45 days to respond. Every associated claim is frozen. A weak response means denial; a well-built packet means payment. We assemble the documentation, draft the response narrative to your specific denial driver, and track the appeal through determination.
An Additional Documentation Request is a claim-specific demand from the MAC — Palmetto GBA for Georgia hospices and HHAs — for medical records and supporting documentation to validate a billed claim. Claims subject to an ADR are held from payment until the documentation is reviewed and the claim is either approved or denied.
A Targeted Probe and Educate audit is a pattern-level review — Palmetto selects a provider based on statistical edit triggers (Bene Sharing patterns, Long-LOS outliers, GIP volume, F2F documentation flags) and audits a cohort of claims simultaneously. TPE reviews can result in denial of an entire claim cohort and escalate to extrapolation if documentation deficiencies are systemic.
Both require a structured, organized response packet. A disorganized response — documents submitted without a narrative framework, without a table of contents, without the specific documentation Palmetto's reviewers are looking for at each denial driver — delays determination and reduces the probability of reversal.
Beneficiary referral patterns suggesting improper financial relationships between the hospice and referring facilities. High-volume same-facility referrals are the primary trigger for Palmetto's active Bene Sharing TPE edit in Georgia.
Beneficiaries with extended length of stay — particularly those exceeding one year on routine home care — trigger documentation scrutiny on CTI narrative adequacy, recertification quality, and functional decline trajectory.
General Inpatient level-of-care claims require specific documentation of symptom management crisis and attending physician orders. The transition documentation from GIP back to RHC is the most frequently deficient component in GIP ADRs.
Untimely F2F encounters, missing attestation language, or F2F attestations not meeting the specificity standard. For HHAs, the 42 CFR 424.22 F2F timing requirement is the most common single denial driver in Georgia Palmetto ADRs.
Every ADR/TPE response engagement covers all four components — we don't charge separately for assembly, narrative, and appeal tracking. The fee reflects the total size of the claim cohort being responded to.
Complete document checklist issued within 24 hours of engagement. We specify exactly which records Palmetto expects for the denial driver identified — CTI narratives, election statements, F2F documentation, GIP orders, IDG records — organized to Palmetto's review format.
Narrative response written to the specific denial driver — Bene Sharing, Long-LOS, RHC, GIP, F2F — using the Palmetto Hospice Coalition Q&A format that Palmetto reviewers are trained to read. Generic responses do not move through the queue the same way.
Assembled packet includes a table of contents, claims detail, documentation organized by claim, and the response narrative. Formatted for Palmetto's electronic submission portal. Delivered to the client for review before submission on or before Day 30 to allow buffer before the Day 45 deadline.
We track the initial determination and file the redetermination appeal if the initial response results in denial. Appeal tracking continues through the first two levels — initial determination and redetermination. ALJ and QIC levels are separately scoped if reached.
This engagement is specifically designed for post-acute providers under Palmetto GBA JM HHH — the MAC for Georgia, South Carolina, North Carolina, Virginia, and West Virginia. Our response frameworks are built around Palmetto's documented review criteria, not generic MAC guidance.
ADR and TPE response for hospices of any size. PPEO hospices — where 100% of claims are in prepayment review — are a particular focus. For PPEO hospices, the response packet is structurally identical to a standard ADR response but needs to be built faster given the prepayment hold timeline.
HHA ADR response covers F2F encounter documentation, OASIS-E2 assessment compliance, skilled nursing visit necessity, and the HHA-specific denial drivers active in Palmetto's current TPE edit set. Reason Code 56900 denials are the most common HHA ADR trigger and have a specific documentation response protocol.
For hospices in active PPEO, claims in prepayment hold require a response before payment is released — not after a denial. The documentation standard is the same as an ADR response, but the timeline is compressed. We prioritize PPEO response requests above standard ADR queue.
A TPE audit covers a cohort of claims simultaneously. Response requires a consistent documentation narrative across all claims in the cohort plus a systemic response addressing the pattern-level finding. We scope TPE responses based on cohort size; larger cohorts (20+ claims) are priced at the higher end of the range.
Submit your request now. We'll identify your denial driver, confirm the claim cohort size, and issue a fixed-fee quote within one business day. Document checklist issued within 24 hours of engagement confirmation.
For active ADRs or PPEO prepayment situations: email directly at hello@prognosisconsulting.com with ADR in the subject line. We flag these for same-day response when operationally feasible.
Urgent ADR requests: email hello@prognosisconsulting.com · Subject: ADR