SNF ADR Update

SNF ADR Management: Prepare for Post-Probe Surge

The SNF 5-Claim Probe & Educate officially ended on June 30, 2025, but for many providers, the scrutiny is just beginning. While CMS guidance indicates that providers with 100% error rates (5/5 claims in error) would be prioritized for Targeted Probe & Educate (TPE), we are finding TPEs initiated for facilities with error rates of 60% or more. Was your SNF stretched thin responding to the 5-claim probe? Get ready—the full TPE process is much more intense.

What to expect for Facilities with Sub-Par 5-Claim Probe Outcomes

If your facility experienced an error rate of 60-100%, it is likely that you will be placed under an expanded focus which often means a significant increase in Additional Documentation Requests (ADRs). Under TPE, facilities can be asked to respond to 20–40 claim requests within just 45 days, requiring rapid, coordinated action to collect records, verify compliance, and submit complete packets on time. For organizations that were already stretched during the 5-Claim Probe & Educate phase, the shift to higher-volume ADRs represents a major operational challenge — and highlights the need for a proactive, organized ADR management process.

The Top Denial Drivers

• • No documentation submitted to the MAC
  • Record received lacked documentation covering the full period from admission through the dates of service under review.
  • SNF certifications/recertifications were missing, late, or incomplete, with no delayed certification on file or with an invalid physician signature.
  • Missing hospital documentation from the qualifying stay.
  • Documentation not supporting PDPM HIPPS codes (Section GG, Section I, active diagnoses, etc.).

Preparing for ADRs —Tips for Building a Medical Review Response System

1. Create a Dedicated ADR Team

• • Assign clear roles for identifying ADR notices have been received, gathering records, writing defensive briefs, and submitting packets.

2. Develop a Standardized ADR Packet Template

• • Consider including labeled dividers: qualifying hospitalization, MDS Assessments, physician orders, nursing notes, MAR/TAR, therapy, etc.
  • Make it as easy as possible for MAC reviewers to find the key documentation needed to approved the claim.

3. Front-Load Clinical & Coding Review

• • Engage MDS and clinical experts at the ADR level to ensure supporting documentation clearly validates the HIPPS codes billed.

4. Maintain a Complete Submission Log

• • Record date of ADR receipt, due date, date sent, confirmation of receipt, and outcome.
  • Track favorable/partial/denied determinations with reasons for denial to spot trends.

5. Keep Copies of Everything

• • Retain a copy of the entire ADR packet, confirmation receipts, and correspondence. This becomes your audit trail if an appeal is needed.

Submitting Documentation Efficiently

• • Monitor the 45-Day Clock: From ADR date to the date you submit documentation, plan for timely completion and track the time closely; request extensions if needed.
  • Submission Options: Generally, the best option is to submit electronically through the MAC’s designated portal. Other options include esMD, fax, and USPS. If mailing, the pages must be one-sided, bundled by claim with a copy of the ADR letter attached for easy identification.
  • Review and Track Response Timelines: MACs generally have 30 days to review once documents are received.

Tracking TPE Review Outcomes

• • Results Letters: Make note of allowed vs. denied or partially denied claims, and opt in for the education offered.
  • Education Opportunities: Use MAC teleconferences/webinars to ask claim-specific questions.
  • Rounds: Up to three TPE rounds are possible (determined by the MAC), depending on your facility error rates in each round. If subsequent rounds of review are required, the MAC may begin requesting documentation as early as 45 days after the education is completed.
  • Post-TPE Monitoring: Once an acceptable error rate is reached, the MAC continues routine monitoring.

Appeals Strategy

• • Appeal Quickly: Redetermination must be filed within 120 days.
  • Develop a Defensive Position Statement: While care details are fresh, outline why documentation supports the billing, using references from CMS regulation and RAI.

Tighten Up Compliance In Advance of ADRs

• • Engage 3rd party QA reviews of MDS coding accuracy and supportive documentation compliance
  • Conduct regular SNF certification & recertification audits
  • Provide substantive skilled documentation training
  • Implement a robust Utilization Review (UR) process
  • Run a Triple-Check Meeting before billing (Check out our blog on UR & Triple Check Essentials and access our Clean Claims Checklist)

The end of the SNF 5-Claim Probe & Educate doesn’t mean audits are slowing down — it simply shifts the focus to the TPE. Facilities with higher error rates are already seeing an increase in ADRs and must be prepared to respond to 20–40 claims within a tight timeframe. Contact your MAC if you are unsure of the claims review outcome from your 5 Claim Probe & Educate.

By putting proactive systems in place now — from ADR teams, to QA audits, and processes for RU and triple-check— providers can reduce denials, protect revenue, and demonstrate strong compliance. The key is organization, documentation, and ongoing staff education. Facilities that plan ahead and standardize their ADR response process will be in the best position to navigate TPE successfully and minimize disruption to care delivery and reimbursement.

Next Steps:

Contact Proactive for assistance in managing Medicare ADRs and Appeals and for advance preparation for Medical Review through:

• • QA review of MDS coding accuracy and supportive documentation
  • Medicare compliance systems risk assessment
  • Skilled documentation training

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