Failing to supply medical records in response to additional documentation requests (ADRs) was Medicare Administrative Contractor (MAC) Palmetto GBA's most common reason for denial of home health claims between April and June 2018, Palmetto data show.
 
Face-to-face encounter requirements not met took the No. 2 slot.
 
Denial code 56900 (Auto denial — requested records not submitted) accounted for the denial of 1,593 claims, Palmetto data show. That’s more than half of the total 2,913 claims denied within that period.
 
Without the records, the MAC was unable to determine medical necessity for those claims. To avoid this denial, Palmetto recommends agencies do the following:
  • Monitor your claim status. If the claim is in status or location SB6001, it’s selected for review and your agency needs to submit associated medical records.
  • Submit records timely. Make it a goal to submit records within 30 days of the ADR date found in the upper left corner of the request. Claims auto deny on day 46.
  • Submit information together. Gather all the information necessary for the claim and submit it all at one time.
  • Attach a copy of the ADR request to each individual claim.
  • Include separate responses. If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Ensure each set of medical records is bound securely so the submitted documentation isn’t detached or lost.
  • Don’t mail packages C.O.D. Palmetto cannot accept them.
  • Double check the address. Return the medical records to the address on the ADR. Be sure to include the appropriate mail code. This ensures responses are promptly routed to the Medical Review Department.
Palmetto GBA’s No. 2 denial reason is face to face
 
Among the 2,913 claims denied that Medicare Administrative Contractor Palmetto GBA denied from April through June 2018, the top denial reason involved auto denials for requested records not being submitted. The second most common denial reason was 5FF2F— face-to-face encounter requirements not met.
 
Note: Palmetto denied 2,455 home health claims from January through March 2018.
Denial Denial description % of claims denied
56900 Auto denial — requested records not submitted 54.7%
5FF2F Face-to-face encounter requirements not met 21.4%
5F023
No plan of care or certification
 9.7%
5FNOA Unable to determine medical necessity of HIPPS code billed as appropriate OASIS not submitted 6.6%
5CHG3 Medical review HIPPS code change due to partial denial of therapy 3.1%
Source: Palmetto GBA
 
Related link: For more tips from Palmetto on how to avoid these common denial codes, visit https://bit.ly/2nC2bfm.