Home Health Top Medical Review Denial Reason Codes
September 2022 – August 2023
The following information provides home health medical review’s most recent YTD denial data. Please review this information and the educational resources to assist with preventing these types of denials. Refer to the Home Health Denial Reason Codes Web page for a complete list of denial codes.
Rank | Denial Code | Denial Description | # of Claims Denied | % of Claims Denied |
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1 | 5HN18 | Skilled nursing services were not medically necessary. | 911 | 29% |
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Rank | Denial Code | Denial Description | # of Claims Denied | % of Claims Denied |
2 | 5HC09 | The initial certification was missing/incomplete/invalid; therefore, the recertification episode is denied | 619 | 20% |
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Rank | Denial Code | Denial Description | # of Claims Denied | % of Claims Denied |
3 | 5HC01 | The physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely. | 577 | 18% |
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Rank | Denial Code | Denial Description | # of Claims Denied | % of Claims Denied |
4 | 5HY01 | The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist. | 455 | 15% |
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Rank | Denial Code | Denial Description | # of Claims Denied | % of Claims Denied |
5 | 56900 | Requested medical records were not received within the 45 day time limit; therefore, we are unable to determine the medical necessity of the services billed and this claim has been denied. If less than 120 days after denial notification on remittance advice, submit records to the contractor requesting records. Do not resubmit the claim. | 131 | 4% |
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Updated: 09.29.23