Denial Reason Codes

Services may be denied when individual case documentation reveals that specific coverage requirements are not met. These coverage requirements are based directly on sections of the Social Security Act (Sections 1870 and 1879), which discuss home health services. When payment is denied, a Medicare Summary Notice (MSN) is issued to the beneficiary detailing the Medicare claims processed by the contractor.

Home health 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) or may be found in the CMS Understanding the Remittance Advice guide.

Types of Denials

Medical Denials	Medical denials are made upon medical review when: Care is determined to not be reasonable and medically necessary Homebound criteria are not met Skilled nursing care is not intermittent Visits are not documented HIPPS code billed is not validated by documentation in the medical record
Administrative Denials	Administrative denials are denials made for all other reasons. Examples of administrative denials include: Excess of orders (more visits made than ordered by the physician) Services billed prior to physician signing Plan of Care Services exceed definition of part-time Administrative visits for nursing assessment Supervisory visits ESRD related visits No physician certification Dependent service with no skilled service ordered Statutory exclusions Excluded services (drugs and biologicals, routine foot care, personal comfort items, orthopedic shoes and appliances) Services provided by another government agency, including services to prisoners

Medical Denials

Medical denials are made upon medical review when:

Care is determined to not be reasonable and medically necessary
Homebound criteria are not met
Skilled nursing care is not intermittent
Visits are not documented
HIPPS code billed is not validated by documentation in the medical record

Administrative Denials

Administrative denials are denials made for all other reasons. Examples of administrative denials include:

Excess of orders (more visits made than ordered by the physician)
Services billed prior to physician signing Plan of Care
Services exceed definition of part-time
Administrative visits for nursing assessment
Supervisory visits
ESRD related visits
No physician certification
Dependent service with no skilled service ordered
Statutory exclusions

Excluded services (drugs and biologicals, routine foot care, personal comfort items, orthopedic shoes and appliances)
Services provided by another government agency, including services to prisoners

The following provides a list of all medical review denial reason codes and the definition used for home health and hospice claims.

Page last updated: March 27, 2008