Documentation to Determination: Winning the ADR, Denial and Appeal Battle

Documentation drives reimbursement integrity in skilled nursing. As oversight expands and medical review activity increases, ADRs, denials, and appeals have become routine checkpoints in the claim lifecycle. The ability to submit clear, timely, and defensible documentation directly impacts revenue, compliance, and operational stability.

To help facilities strengthen processes and protect reimbursement, Functional Pathways developed this practical guide to navigating medical reviews with confidence.

In this white paper you will learn:

• What triggers ADRs and how to respond effectively
• The difference between technical and clinical denials
• How Triple Check prevents errors before claim submission
• What CMS review programs evaluate and why it matters
• Strategies for stronger appeals that support medical necessity
• Best practices for audit readiness and workflow alignment

Winning the ADR, denial, and appeal battle starts with disciplined systems, accurate documentation, and proactive compliance.