PGBA Home Health Medical Review Top Denial Reason Codes

PGBA recently posted this information when filing claims to prevent denials and to ensure your HHA claims are processed timely. A reference section has been added at the end of each denial code to provide an additional resource for information on how to avoid these denials. Please note these references are not all inclusive.

1. 56900 – Lack of Response to Medical Record Request (Refer to Section 1— Denial Reason Code 56900)
Section 1- Denial Reason Code 56900
The denial reason 56900, lack of response to Additional Development Requests (ADRs), has been reported as one of the top denial reasons for most of these benefit types. Since 56900 is common to most benefit types, we have listed this denial code separately to encourage providers to follow the instructions in the How to Avoid a Denial section before submitting claims to Palmetto GBA. Following these instructions should decrease delays in processing your claims.

Reason for DenialMedical records were not received in response to an ADR in the required time frame; therefore, we were unable to determine medical necessity.

How to Avoid a Denial

• Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted.

• Alert your mail staff that the ADRs will be mailed by Palmetto GBA in bright yellow envelopes with “ADR REQUESTS TIME SENSITIVE” stamped in red on the outside of the envelope to assist them in readily identifying the ADRs.

• Be aware of the need to submit medical records within 30 days of the ADR date. The ADR date is in the upper left corner of the ADR request.

• Gather all information needed for the claim and submit it all at one time.

• Submit medical records as soon as the ADR is received.

• Attach a copy of the ADR request to each individual claim.

• If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Ensue each set of medical records is bound securely so the submitted documentation is not detached or lost.

• Do not mail packages C.O.D.; we cannot accept them.

• Return the medical records to the address on the ADR. Be sure to include the appropriate mail code. This ensures your responses are promptly routed to the Medical Review Department.

2. 5CHG1 – Medical Review HIPPS Code Change/Documentation Contradicts M0 Item(s)
Reason for Denial

The services billed were paid at a different payment level. Based on medical review, the original HIPPS code was changed.

How to Avoid a Denial
To avoid changes for this reason, the documentation should paint a consistent picture of the patient’s condition.

For more information, refer to:
• Outcome and Assessment Information Set Implementation Manual www.cms.hhsgov/oasis/

• American Health information Management Association (Web based training course available) –

• Centers for Disease Control and Prevention lCD and ICF Home Page

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