CorporateBusiness Services

Denial Reason Codes

Services may be denied when individual case documentation reveals that specific coverage requirements are not met. The following links provide a list of all CGS medical review denial reason codes by provider type and the definition.

Home health and hospice 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.

Medical denials are made upon medical review. Examples include:

Home Health Hospice
Care is determined to not be reasonable and medically necessary Care is determined to not be reasonable and medically necessary
Homebound criteria are not met Patient is not/no longer terminal
Skilled nursing care is not intermittent Level of care is not supported
Visits are not documented Physician's services not documented
HIPPS code billed is not validated by documentation in the medical record.  

Administrative denials are denials made for other reasons. Examples include:

Home Health Hospice
Excess of orders (more visits made than ordered by physician) Certification/recertification untimely
Services billed prior to physician signing Plan of Care Certification/recertification not signed
Services exceed definition of part-time Notice of election is missing or incomplete
Administrative visits for nursing assessment Plan of care is missing or incomplete
Supervisory visits  
ESRD related visits  
No physician certification  
Dependent service with no skilled service ordered  
Statutory exclusions
  • Excluded services (drugs and biological, routine foot care, personal comfort items, orthopedic shoes and appliances)
  • Services provided by another government agency, including services to prisoners
 

Updated: 03.06.13


Two Vantage Way, Nashville, TN 37228 ©2014 CGS Administrators, LLC. All Rights Reserved