Denial Reason Codes
Services may be denied when individual case documentation reveals that specific coverage requirements are not met. The following links provide a list of all CGS medical review denial reason codes by provider type and the definition.
Home health and hospice agencies receive a remittance advice (RA), which communicates claim determinations. The RA displays the ANSI reason code in the "RC" or "REM" column. The reason code denial definition can be viewed online in the Fiscal Intermediary Standard System (FISS).
Medical denials are made upon medical review. Examples include:
Home Health | Hospice |
---|---|
Care is determined to not be reasonable and medically necessary | Care is determined to not be reasonable and medically necessary |
Homebound criteria are not met | Patient is not/no longer terminal |
Skilled nursing care is not intermittent | Level of care is not supported |
Visits are not documented | Physician's services not documented |
HIPPS code billed is not validated by documentation in the medical record. |
Administrative denials are denials made for other reasons. Examples include:
Home Health | Hospice |
---|---|
Excess of orders (more visits made than ordered by physician) | Certification/recertification untimely |
Services billed prior to physician signing Plan of Care | Certification/recertification not signed |
Services exceed definition of part-time | Notice of election is missing or incomplete |
Administrative visits for nursing assessment | Plan of care is missing or incomplete |
Supervisory visits | |
ESRD related visits | |
No physician certification | |
Dependent service with no skilled service ordered | |
Statutory exclusions
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Updated: 05.26.15