Hospice Audit Readiness: Documentation and ADR Response

Short answer: Hospice audit readiness starts with a complete, retrievable record for the claim under review: the applicable certification, patient-specific clinical support, required face-to-face documentation, election materials, and every item named in the contractor’s request. CMS identifies missing signatures, incomplete certification or recertification, and records that do not support eligibility or medical necessity among common review errors.^[1][2]

This is an operations guide, not a guarantee of payment or audit outcome. The controlling requirements depend on current federal rules, the patient’s record, the specific claim, the review contractor, and applicable Medicare Administrative Contractor guidance.

What is a hospice medical review or ADR?

Medicare medical review contractors examine records and related information to assess whether a claim meets applicable coverage, coding, billing, and medical-necessity requirements. An Additional Documentation Request (ADR) asks a provider to submit records supporting one or more claims. The request letter identifies what is being reviewed and how to submit the response; follow its instructions and deadline.^[2]

One review pathway is Targeted Probe and Educate (TPE). CMS describes TPE as a nationwide program that uses data analysis to select providers or services for review and education. A typical round involves 20 to 40 claims, with additional rounds possible. CMS says common hospice claim errors include a missing certifying-physician signature, encounter notes that do not support eligibility, documentation that does not support medical necessity, and incomplete initial certifications or recertifications.^[1]

Build the record around the claim and benefit period

Start by identifying the claim, patient, dates of service, benefit period, and exact scope of the request. Then assemble the records that support the billed services during the review period. CMS notes that relevant supporting documentation may include records from before the review period, depending on the claim and request.^[2]

• Certification or recertification: include the applicable benefit-period dates, required signatures and dates, and the physician’s individualized narrative. See our hospice recertification documentation guide.
• Clinical support: organize the notes and findings that support the physician’s patient-specific prognosis. A summary should point back to the source record and preserve relevant dates and context.
• Face-to-face documentation: for the third and later benefit periods, include the required encounter documentation and attestation with the certification record. Confirm the applicable timing and content requirements in current CMS guidance.^[3]
• Election materials: include the beneficiary election statement and any associated addendum required for the case. CMS states that, beginning October 1, 2026, hospices must provide all Medicare beneficiaries an election-statement addendum addressing coverage of non-hospice services at the time of election. If all services are included under the hospice benefit, CMS says that may be denoted on the addendum.^[4]
• Claim-specific records: include the documentation requested for the billed services and the period under review, not an unrelated bulk export.

CMS also publishes provider-level data through its Service and Spending Variation Index. Our SSVI guide explains what this claims-based signal measures and how hospice leaders can use it as a review prompt.

Use a repeatable ADR response workflow

1. Log and route the request. Record the receipt date, claim identifiers, due date, review contractor, requested records, and accountable owner. Maintain current correspondence contact information and monitor contractor portals.
2. Use the ADR letter as the response cover. CMS recommends attaching a copy of the ADR letter as the first page so the submission can be matched to the correct patient and claim.^[2]
3. Gather the requested record. Include the applicable certifications, clinical notes, election materials, and other records specified by the request. Check that dates, signatures, and benefit-period references are legible and consistent.
4. Check completeness against the request. Use a simple checklist to identify missing items, explain any unavailable record through the contractor’s process, and confirm that the submission follows the delivery method and deadline in the letter.
5. Keep a submission trail. Save what was sent, when it was sent, how it was transmitted, and any delivery confirmation or follow-up. If the deadline is at risk, contact the contractor promptly and follow its instructions.

What does an audit-ready record make easy to verify?

A well-organized record does not add new eligibility criteria. It makes it easier for the reviewer to find the information already documented and assess it in context. The file should make the source, date, and relationship of each item to the claim clear, while preserving the clinician’s original documentation and judgment.

CMS’s Medicare Benefit Policy Manual, Chapter 9, requires a written certification for each benefit period and supporting clinical information in the medical record. It specifies the clinical findings, physician signatures and dates, benefit-period dates, and brief narrative explanation the certification must contain. The manual also sets the timing and documentation requirements for face-to-face encounters before the third and later benefit periods. Apply the current manual and relevant local coverage guidance to the claim.^[3]

Questions hospice operators often ask

Does an audit-ready checklist guarantee a claim will be paid?

No. A checklist helps organize requested records and identify omissions. Payment depends on the applicable coverage rules and the facts documented in the patient’s record and claim.

Does every hospice enter the TPE program?

No. CMS says TPE uses data analysis to select providers and services for targeted review. It is not a routine review of every hospice claim.^[1]

What should we send for an ADR?

Send all records requested in the ADR by the stated deadline and submission method. CMS recommends including the ADR letter first and submitting documentation that supports the claim, which may include records from before the review period when relevant.^[2]

What changed for hospice election addenda in October 2026?

CMS states that hospices must provide an addendum to the election statement to all Medicare beneficiaries at election, describing coverage of non-hospice services. When all services are included, the addendum may say so.^[4]

How Aether fits

Aether organizes referral records into a structured case with source-linked evidence and visible gaps for physician review. It supports case preparation and operational follow-up; the hospice’s clinicians and physician retain clinical and certification responsibility. Learn more about hospice eligibility review software or explore the full hospice eligibility operations resource hub.

Sources

1. Centers for Medicare & Medicaid Services, Targeted Probe and Educate (TPE).
2. Centers for Medicare & Medicaid Services, Additional Documentation Request (ADR).
3. Centers for Medicare & Medicaid Services, Medicare Benefit Policy Manual, Chapter 9: Coverage of Hospice Services.
4. Centers for Medicare & Medicaid Services, Provisional Period of Enhanced Oversight and Expanded Prepayment Review Questions and Answers.

This resource is general operational information, not legal advice or a patient-specific clinical determination. Consult current CMS requirements, the applicable Medicare Administrative Contractor, and qualified compliance and clinical leadership.