Skip to Main Content

Print | Bookmark | | Font Size: + |

May 4, 2021

Home Health Ordering/Referring Denials

The CGS Provider Education and Outreach (POE) department has been focusing on reducing denials related to the following home health ordering/referring denial reason codes. Data from September 2020 through March 2021 shows a total of 2,266 claims denied with these reason codes. The following provides the number of claims denied and the reason code description.

  • 32072 (923 claims denied)
    • The physician has a termination date in the Provider Enrollment, Chain, and Ownership System (PECOS) that equals or is earlier than the dates of service on the claim.
  • 37236 (1035 claims denied)
    • The attending physician's National Provider Identifier (NPI) is not found in PECOS; or
    • The first four letters of the last name of the attending physician on the claim do not match the last name of the NPI in PECOS; or
    • The specialty code is not a valid eligible code.
  • 37247 (308 claims denied)
    • The referring physician's NPI on the claim is not present on the eligible referring physician file, or the referring physician's NPI on the claim is present, but the last name of the referring physician does not match the last name of the NPI record in the eligible referring physician file from PECOS; or
    • The specialty code is not a valid eligible code.

When a home health claim receives an ordering/referring denial, the only recourse to receive payment is to request a Reopening, which can cause providers extra time and money.

To prevent these types of denials, refer to the following resources:

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved