What happens if a provider misses First Coast's 45-day ADR deadline?

First Coast sets the claim to deny automatically on day 46 if the requested documentation has not arrived. The 45-day clock runs from the date printed on the ADR letter, not the date it is received or opened, so mailed responses need enough lead time to arrive before the deadline. Electronic submission through First Coast's secure online portal, esMD, or fax avoids that transit risk entirely.

What is Targeted Probe and Educate and how does it differ from a regular First Coast medical review?

Targeted Probe and Educate reviews a small sample of a provider's claims against one specific billing issue, then follows with individualized education on the result. If the error rate does not improve, First Coast escalates to a second and then a third round. Other First Coast medical review activities and additional review programs run independently of TPE and can proceed on the same provider at the same time.

Which states and territories does First Coast Service Options cover for Medicare claims?

First Coast Service Options processes Medicare Part A and Part B claims for Florida, Puerto Rico and the U.S. Virgin Islands as the Jurisdiction N Medicare Administrative Contractor. Durable medical equipment claims from the same providers route to a different DME MAC, and home health and hospice claims route to Palmetto GBA in Florida or National Government Services in Puerto Rico and the Virgin Islands.

First Coast Service Options Medicare Audits and Medical Review

Physicians, pharmacies and other providers in Florida, Puerto Rico and the U.S. Virgin Islands answer to one contractor for Medicare medical review: First Coast Service Options. First Coast is the Medicare Administrative Contractor (MAC) that processes Part A and Part B claims there, decides which claims get pulled for review, and mails the additional documentation request (ADR) letter that starts a fixed response clock. A provider who treats that letter as routine mail can watch the claim deny automatically before a response is ever submitted.

First Coast's Medicare Jurisdiction

First Coast Service Options holds the MAC contract for Jurisdiction N, covering Florida, Puerto Rico and the U.S. Virgin Islands. Per CMS's own contractor directory, First Coast handles both Part A and Part B claims in all three jurisdictions. Durable medical equipment claims route to a separate DME MAC, and home health and hospice claims route to Palmetto GBA in Florida or National Government Services in Puerto Rico and the Virgin Islands. The first question in any matter is confirming that First Coast, not one of these other contractors, issued the notice.

How a First Coast ADR Arrives

When First Coast selects a claim for review, it mails the ADR letter to the practice address on file in the Provider Enrollment, Chain and Ownership System (PECOS). The 45 calendar day response clock starts on the date of the letter, not the date the provider opens the mail, and First Coast sets the claim to deny automatically on day 46 if the documentation has not arrived. First Coast accepts documentation through its secure online portal, through esMD, by fax to the number printed on the ADR letter, or by mail. A missing or illegible signature can lead the contractor to request a signature log or attestation statement, with its own 20 calendar day window. Once documentation is submitted on time, CMS requires a determination within 30 calendar days.

Targeted Probe and Educate and Other Medical Review

Current First Coast review includes Targeted Probe and Educate (TPE), the CMS program reviewing a small claim sample against one billing issue, then escalating to a second and third round if the error rate does not improve. The billing issue behind a First Coast ADR varies: a claim flagged under First Coast's post-pandemic telehealth billing edits, a modifier 25 question over a separately identifiable evaluation and management service, or a modifier 59 unbundling edit each carry their own standard. First Coast also runs review activities outside TPE, so passing one round does not clear every open issue.

First Coast's Provider Portal and LCD Library

First Coast's secure provider portal is the hub for ADR submissions and claim status. Coverage policy sits separately, in an index of the local coverage determinations (LCDs) First Coast has adopted. An LCD, not a national coverage determination, can be the basis a reviewer cites for denying a claim, which is why confirming the applicable LCD is a first step in answering any First Coast medical review.

What an Unfavorable Review Can Trigger

A string of denied claims does not stay isolated to the claims First Coast tested. It can apply extrapolation, projecting the error rate found in a sample of claims across a larger universe of unreviewed claims, and the result is a recoupment demand far larger than the claims actually reviewed. First Coast's own review sits apart from a Recovery Audit Contractor (RAC) audit, and a provider can face more than one review type on the same claims.

The 45-day clock on a First Coast ADR starts on the date of the letter, not the date a provider opens it, and First Coast sets the claim to deny automatically on day 46.

Why Early Legal Counsel Is Critical

It is critical that providers promptly retain experienced healthcare defense counsel upon receiving a First Coast ADR, a TPE notice, or any related medical review correspondence. Early legal intervention can help protect the provider's rights, support an accurate response, avoid inadvertent admissions, preserve relevant defenses, and allows counsel to communicate with First Coast on the provider's behalf. Delaying representation can affect the outcome and expose the provider to an extrapolated recoupment demand that a timely response could have narrowed or avoided.

How Health Law Alliance Can Help

Health Law Alliance represents providers nationwide, including those answering a First Coast ADR, a Targeted Probe and Educate round, or a related Medicare medical review.

Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience.

If a First Coast ADR or TPE notice has arrived, contact Health Law Alliance's Medicare audit defense team for a free, confidential consultation before the 45-day clock runs.