Two out of every three claims were denied following a recent post-payment medical review of 1,000 claims by National Government Services (NGS), a Medicare administrative contractor (MAC) serving agencies in 19 states. The MAC published the results June 28.
The top reason for denial was Reason Code 56900: No response from medical record request, with 154 claims denied because home health agencies failed to respond to the documentation requests.
The other top reasons included:
- Reason Code 55HTP: Certification missing/incomplete/invalid (145 claims)
- Reason Code 5H3V: Skilled nursing services not medically necessary (53 claims)
- Reason Code 5H3R: Requirements not met for daily care (51 claims)
CGS expands medical review into pandemic-era claims
Also June 28, another MAC, CGS, announced medical reviews had begun on claims filed since the beginning of the pandemic. Earlier in the month, CMS announced that medical reviews could begin on claims on and after March 1, 2020.