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.

The information does not support the need for this many home health aide visits.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 50.2 for information regarding Home Health Aide Services.

Based on our review of the information provided, the home health aide visits specified did not include personal care services or services that were necessary to maintain the beneficiary's health or help with treatments.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 50.2 for information regarding Home Health Aide Services.

This claim was denied after review. The provider's determination of non-coverage is correct.

Reference:
Please refer to CMS Publication 100-04, Chapter 10, Section 50 for information regarding Beneficiary –Driven Demand Billing.

The certification was invalid since the required face-to-face encounter was missing/incomplete/untimely.

• There was no clinical documentation submitted for a face-to-face encounter visit to support the referral for homecare/certification.
• Only a face-to-face attestation form was submitted, and not the required clinical note for the face-to-face assessment.  
• The face-to-face encounter visit submitted did not occur within the required timeframe of 90 days prior or 30 days after the start of care date.
• The face-to-face encounter assessment was not performed by an allowed provider type, which are a physician, nurse practitioner, physician's assistant, or certified nurse midwife.
• The face-to-face was not related to the primary reason for homecare.
• The five elements of the certification for the referral to homecare were not attested to by the same physician or allowed practitioner, making the certification statement incomplete.
• The certifying (facility) physician did not identify the community physician or allowed practitioner taking over the beneficiary's care, and the community physician did not attest to the date of the face-to-face indicating awareness/acknowledgement of the assessment.
• The physician or allowed practitioner signed the certification/plan of care prior to the date of the face-to-face encounter occurring. The certifying physician and/or allowed practitioner must have a face to face encounter assessment before they certify the beneficiary for eligibility for home healthcare.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Sections 30.5.1.1-30.5.1.2 and publication 100.08, Chapter 6, Sections, 6.2-6.2.6 for information regarding Certification and Recertification Requirements.

Physician or allowed practitioner's plan of care and/or certification present – signed but signature dated untimely.

• The physician or allowed practitioner signed the plan of care on -----and the receipt date for the claim was -----
• The physician or allowed practitioner signed the plan of care; however, the date is illegible rendering the certification/plan of care untimely.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.2.4 for information regarding Certification Requirements and publication 100-08, Chapter 3, Section 3.3.2.4 for specific information regarding Signature Requirements.

Physician's plan of care and/or certification present – signed but signature is not dated.

• The physician signature was not dated per plan of care.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.2.4 for information regarding certification requirements and publication 100-08, Chapter 3, Section 3.3.2.4 for specific information regarding Signature Requirements.

Physician or allowed practitioner's plan of care and/or certification present-no signature.

• Unable verify the physician or allowed practitioner's signature as being, electronic, digitalized or facsimile. Medicare regulations do not allow stamped signatures. Certification deemed invalid/unsigned by physician.

Reference:
Please refer to CMS Publication 100-08, Chapter 3, Section 3.3.2.4 for specific information regarding Signature Requirements.

No physician's plan of care and no certification present.

• The plan of care for the DOS ---- to---- was not submitted.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.2 for specific information regarding Certification/Plan Of Care Requirements.

Certification Missing or invalid

• The certification statement on the plan of care was altered/illegible and/or did not contain all the required elements.
• The certification statement was missing on the plan of care.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Sections 30.2 and 30.5.1 for specific information regarding Certification/Plan Of Care Requirements.

Physician's Plan of Care missing or invalid.

• The plan of care for (therapy type) was not submitted.
• The plan of care did not contain ----- rendering it invalid.
• The plan of care for therapy did not include measurable treatment goals that pertained directly to the beneficiary's condition and expected duration of therapy services.
• The course of therapy was not approved by the physician after the consultation with the therapist occurred.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.2 for specific information regarding Certification/Plan Of Care Requirements.

The recertification estimate of how much longer skilled services are required is missing/incomplete/invalid.

• The physician's estimate of how much longer skilled care would be required was missing.
• The physician estimate of how much longer skilled care would be required was incomplete/invalid due to being unclear as it did not contain a measurable unit of time.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Sections 30.5.1-30.5.2 and publication 100.08, Chapter 6, Sections 6.2- 6.2.6 for information regarding Certification and Recertification Requirements.

The initial certification was missing/incomplete/invalid; therefore, the recertification episode is denied.

• There was no clinical documentation submitted for a face-to-face encounter visit to support the start of care referral for homecare/certification.
• Only a face-to-face attestation form was submitted, and not the required clinical note for the face-to-face assessment.  
• The face-to-face encounter visit submitted did not occur within the required timeframe of 90 days prior or 30 days after the start of care date.
• The face-to-face encounter assessment was not performed by an allowed provider type, which are a physician, nurse practitioner, physician's assistant, or certified nurse midwife.
• The five elements of the certification for the referral to homecare were not attested to by the same physician, making the certification statement incomplete.
• The certifying (facility) physician did not identify the community physician taking over the beneficiary's care, and the community physician did not attest to the date of the face-to-face indicating awareness/acknowledgement of the assessment.
• The physician signed the certification/plan of care prior to the date of the face-to-face encounter occurring. The certifying physician and/or allowed practitioner must have a face-to-face encounter assessment before they certify the beneficiary for eligibility for home healthcare.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Sections 30.5.1.1-30.5.1.2 and publication 100.08, Chapter 6, Sections 6.2- 6.2.6 for information regarding Certification and Recertification Requirements.

MR downcode/documentation contradicts OASIS M item(s).

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.2.1 for specific information regarding Therapy Requirements. CMS Publication 100-04, Chapter 10, Sections 10.1.9-10.1.19.3 regarding Coding.

MR downcode/provider billed higher category than OASIS M item(s) billed.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.2.1 for specific information regarding Therapy Requirements. CMS Publication 100-04, Chapter 10, Sections 10.1.19-10.1.19.3 regarding Coding.

Partial denial for therapy resulting in MR downcode.

• The therapy documentation does not support that the assessment, measurement and documentation of effectiveness was completed at the required interval(s) and/or was not completed by a therapist. There was no 30 day reassessment submitted. Deny visits dated ----- (therapy denial 5HY02, which may result in downcode)

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.2.1 for specific information regarding Therapy Requirements. CMS Publication 100-04, Chapter 10, Sections 10.1.9-10.1.19.3 regarding Coding.

Partial denial resulting in a LUPA.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.2.1 for specific information regarding Therapy Requirements. CMS Publication 100-04, Chapter 10, Sections 10.1.9-10.1.19.3 regarding Coding.

HIPPS reduced for non-routine supplies (NRS).

Reference:
Please refer to CMS Publication 100-04, Chapter 10, Section 10.1.9 regarding OASIS Coding.

Demand bill reversed and paid in part or in full.

Documentation submitted does not support homebound status.

• The beneficiary was noted per documentation to leave home frequently, without a taxing effort.  (add in evidence as need per claim)

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.1 for information regarding Homebound Criteria.

Homebound status not met due to ineligible place of residence.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.1.2 for information regarding Patients Place Of Residence.

Insufficient documentation of hours to determine if the part-time requirement is met.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Sections 30.4 and 40.1.3 for information regarding Care on an Intermittent Basis.

Documentation does not support exemption from endpoint for daily insulin administration.

• Documentation did not support why the beneficiary could not self-inject insulin and/or that there was not a willing and able caregiver to perform administration.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.4 for information regarding Care on an Intermittent Basis.

These services are denied because it does not meet the part time or intermittent criteria. Skilled nursing care exceeds 28/35 hours.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.4 for information regarding Care on an Intermittent Basis.

These services are denied because it does not meet the part time or intermittent criteria. Home health aide care exceeds 28/35 hours.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.4 for information regarding Care on an Intermittent Basis.

Medicare will pay for daily skilled nursing care when the beneficiary needs daily care for a temporary, but not indefinite period. However, the physician must document the need for daily care and determine when daily care is realistically expected to end. Based on the medical information provided, these requirements were not met.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.4 for information regarding Care on an Intermittent Basis.

To qualify for Medicare home health services the beneficiary needs to have intermittent skilled nursing care visits. When the medical need is only for a single skilled nursing visit, Medicare cannot pay for the nurse because the intermittent requirement is not met.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.4 for information regarding Care on an Intermittent Basis.

Skilled observation was not needed from the start of care (SOC).

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.1 for information regarding Skilled Observation.

Documentation does not support the medical necessity of additional teaching and/or training.

• Skilled nurse notes indicated repetitive teaching -

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.3 for information regarding Skilled Teaching and/or Training Activities.

Documentation does not support why medication can't be self-injected.

• Documentation did not support why the beneficiary could not self-inject their medication and/or that there was not a willing and able caregiver to perform administration.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.4 for information regarding Skilled Administration of Medications.

Documentation does not support that Epogen administration was medically necessary.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.4 for information regarding Skilled Administration of Medications.

Documentation does not support why insulin can't be self-injected.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.4 for information regarding Skilled Administration of Medications.

Vitamin B-12 is not reasonable and necessary based on diagnosis.

• Documentation did not reveal that this beneficiary received vitamin B-12 injections for any of the Medicare required specific conditions/diagnosis's

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.4 for information regarding Skilled Administration of Medications.

More skilled nursing visits were provided than medically necessary.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.1 for information regarding Reasonable and Necessary Skilled Nursing Care.

Documentation does not support that skilled management and evaluation (M&E) of care plan is reasonable and necessary.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.2 for information regarding Management and Evaluation of a Patient Care Plan.

Monthly mediport flush without administration of medication is not medically necessary.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.4 for information regarding Skilled Administration of Medications.

Medicare requirements are that skilled observation is needed as long as the reasonable potential for change in condition exists. There was no further need for skilled observation.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.1 for information regarding Skilled Observation.

Documentation does not support the frequency of Venipunctures.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.13 for information regarding Venipuncture.

Documentation does not support more than one Vitamin B12 injection in the same month.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.4 for information regarding Skilled Administration of Medications.

The Medicare program does not consider prefilling of insulin syringes to be a skilled nursing service.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.4 for information regarding Skilled Administration of Medications.

Based on the documentation submitted, the type of medication received is not accepted by Medicare as an effective treatment for the medical condition.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.4 for information regarding Skilled Administration of Medications.

Documentation does not support why the injectable medication could not be given orally.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.4 for information regarding Skilled Administration of Medications.

Documentation does not support that the wound care required the skills of a nurse.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.8 for information regarding Wound Care.

Documentation does not support the medical necessity of catheter changes more frequently than once a month.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.2.7 for information regarding Catheters.

Skilled nursing services were not medically necessary.

• Skilled nursing visits for general assessment, medication planner prefill/mgmt., repetitive teaching. (alter according to your specific claim)

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 40.1.1 for information regarding Reasonable and Necessary Skilled Nursing Care.

Medicare requires that all services be ordered by a physician. The denied visits were not ordered or exceeded the physician's orders.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.2.2 for information regarding Specificity of Orders.

The order(s) are incomplete as they must indicate discipline, frequency duration, and treatment.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.2.2 for information regarding Specificity of Orders.

Medicare requirements for Home Health require that physician order(s) must be received either verbally or in writing before delivery of the services. These orders must be signed prior to billing the services.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.2.5 for information regarding use of Verbal Orders.

Medicare requirements for home health require that physician order(s) must be signed prior to billing the services.

• The (plan of care or add orders) dated ----- to ----- verbal start of care was signed on ----- and the physician signed ----, (service orders) dated (---) were denied as they did not have timely orders.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.2.4 for information regarding Timeliness of Signature.

No documentation of services rendered.

The OASIS was not submitted to the repository and/or not submitted prior to billing the final claim.
(Change Request 9585, final claims submitted with dates of service on or after April 1, 2017, will deny when the Outcome and Assessment Information Set (OASIS) assessment has not been submitted timely.)

Reference:
Please refer to CMS Publication 100-04, Chapter 10, Sections 10.1.19-10.1.19.3 for information regarding the OASIS.

Medical necessity not supported as an incorrect OASIS was submitted.

Reference:
Please refer to CMS Publication 100-04, Chapter 10, Section 10.1.19 for information regarding the OASIS.

Based on medical review of the documentation, the HIPPS code has been recoded, resulting in a change to Medicare payment.

Reference:
Please refer to CMS Publication 100-04, Chapter 10, Section 10.1.8 for information regarding Coding.

Information provided does not support the medical necessity for medical social worker visit(s).

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 50.3 for information regarding Medical Social Services.

Services for the sole purpose of evaluating the patient for the Medicare home health benefit are not considered billable visits.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 70.2 for information regarding Evaluation Visits.

A skilled nursing assessment visit for the sole purpose of admission is an administrative cost and is not billable.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 70.2 for information regarding Evaluation Visits.

Home health service(s) were billed in error.

Reference:
Please refer to CMS Publication 100-04, Chapter 10, Section 10.1.10 for information regarding Provider Billing.

Service(s) are not covered as the beneficiary was not home.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 30.1 and 30.1.2 for information regarding Confined to Home.

These services are denied as there was no qualifying skilled service provided.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 50.1 for information regarding Qualifying Skilled Services.

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.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Sections 40.2 -40.2.4.3 for information regarding Therapy Services.

The therapy documentation does not support that the Assessment, Measurement and Documentation of Therapy Effectiveness was completed at the required interval(s) and/or was not completed by a therapist.

(see also under downcode 5HD03)

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Sections 40.2 -40.2.4.3 for information regarding Therapy Services.

Medicare can cover home health services only when intermittent skilled nursing care or physical or speech therapy is also needed. Since the beneficiary did not need these services, no payment can be made for the services listed.

Reference:
Please refer to CMS Publication 100-02, Chapter 7, Section 50.1 for information regarding Qualifying Skilled Services.