CGS’ top denial reasons involving the “probe and educate” review
Effective Feb 22, 2016
Published Feb 22, 2016
Last Reviewed Feb 22, 2016
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Medicare Administrative Contractor CGS has partially or fully denied 508 of 595 claims it has reviewed early on during CMS home health “probe and educate” review.
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#1 denial reason
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Certification issues — 57%
- Face to face missing/incomplete/invalid (91%)
- Untimely plan of care (POC)/certification (2%)
- POC/certification not signed (2%)
- Missing certification/POC (2%)
- Recertification estimate missing (1%)
- Initial cert missing/invalid (1%)
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#2 denial reason
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No response to ADR — 30%
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#3 denial reason
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Medical necessity of therapy services — 7%
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Source: CGS
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