Skip to Main Content

Print | Bookmark | Font Size: + | –

Home Health Medical Review Denials

Top MR Denials

This table shows the top Medical Review (MR) denial data for a calendar quarter. See the MR Denial Reason Codes table for resources to help you avoid future claim denials.

Rank Reason Code Description # of Claims Denied % of Claims Denied
1 5HN18 Skilled nursing services weren't medically necessary. 364 25%
2 5HC01 The physician certification is invalid since the required face-to-face encounter is missing, incomplete, or untimely. 295 20%
3 5HC09 The initial certification is missing, incomplete, or invalid; therefore, the recertification episode is denied. 257 18%
4 5HY01 The medical documentation submitted doesn't show that therapy services are reasonable and necessary and at a level of complexity that requires the skills of a therapist. 224 15%
5 56900 Requested medical records weren't received within the 45-day time limit; therefore, we're unable to determine the medical necessity of the services billed and this claim is denied. If less than 120 days after the denial date on the remittance advice, submit records to the contractor requesting records. Don't resubmit the claim. 61 4%

MR Denial Reason Codes

This table lists each Medical Review (MR) denial reason code, a description, and resources to help you avoid future claim denials.

Reason Code Description
56900

Requested medical records were not received within the 45-day time limit; therefore, we are unable to determine the medical necessity of the services billed and this claim has been denied. If less than 120 days after denial notification on remittance advice, submit records to the contractor requesting records. Do not resubmit the claim.

Resources:
5HA01

The information does not support the need for this many home health aide visits.

Reference:
5HA02

Based on our review of the information provided, the home health aide visits specified did not include personal care services or services that were necessary to maintain the beneficiary's health or help with treatments.

Reference:
5HBEN

This claim was denied after review. The provider's determination of non-coverage is correct.

Reference:
5HC01

The certification was invalid since the required face-to-face encounter was missing/incomplete/untimely.

  • Clinical documentation for a face-to-face encounter visit to support the referral for homecare/certification is missing.
  • A face-to-face attestation form was submitted, but the required clinical note for the face-to-face assessment is missing.
  • The face-to-face encounter visit didn't occur within the required timeframe (90 days prior to or 30 days after the start of care date).
  • An allowed practitioner (physician, nurse practitioner, physician assistant, certified nurse midwife) didn't perform the face-to-face encounter assessment.
  • The face-to-face wasn't related to the primary reason for home care.
  • The same physician or allowed practitioner didn't attest to the 5 certification elements for the referral to home care.
  • The certifying (facility) physician didn't identify the community physician or allowed practitioner taking over the beneficiary's care, and the community physician didn't attest to the face-to-face date (to indicate awareness of or acknowledge the assessment).
  • The physician or allowed practitioner signed the certification/plan of care prior to the face-to-face encounter date. The certifying physician or allowed practitioner must have a face-to-face encounter assessment before they certify the beneficiary for home health care eligibility.

Resources:
5HCO2

Physician or allowed practitioner's plan of care and/or certification present – signed but signature dated untimely.

  • The physician or allowed practitioner signed the plan of care on -----and the claim receipt date was-----
  • The physician or allowed practitioner signed the plan of care; however, the date is illegible.

Reference:
5HC03

Physician's plan of care and/or certification present – signed but signature is not dated.

  • The physician signature wasn't dated per the plan of care.

Reference:
5HC04

Physician or allowed practitioner's plan of care and/or certification present-no signature.

  • Unable to verify the physician or allowed practitioner's signature.

Reference:
5HC05

No physician's plan of care and no certification present.

  • The plan of care for the dates of service requested wasmissing.

Reference:
5HC06

Certification missing or invalid.

  • The plan of care certification statement was missing, altered, illegible, or didn't contain all required elements.

Reference:
5HC07

Physician's Plan of Care missing or invalid.

  • The therapy plan of care was missing.
  • The plan of care didn't contain all required elements.
  • The therapy plan of care didn't include measurable treatment goals pertaining directly to the beneficiary's condition and expected duration of therapy services.
  • The physician didn't approve the course of therapy after the therapist's consultation.

Reference:
5HC08

The recertification estimate of how much longer skilled services are required is missing/incomplete/invalid.

  • The physician's estimate of how much longer skilled care is required was missing or didn't contain a measurable unit of time.

Reference:
5HC09

The initial certification was missing/incomplete/invalid; therefore, the recertification episode is denied.

  • Clinical documentation for a face-to-face encounter visit to support the start of care referral for home care/certification was missing.
  • A face-to-face attestation form was submitted, but the required clinical note for the face-to-face assessment was missing.
  • The face-to-face encounter visit didn't occur within the required timeframe (90 days prior to or 30 days after the start of care date).
  • An allowed practitioner (physician, nurse practitioner, physician assistant, certified nurse midwife) didn't perform the face-to-face encounter assessment.
  • The same physician didn't attest to the 5 certification elements for the referral to home care.
  • The certifying (facility) physician didn't identify the community physician taking over the beneficiary's care, and the community physician didn't attest to the face-to-face date (to indicate awareness of or acknowledge the assessment).
  • The physician signed the certification/plan of care prior to the face-to-face encounter date. The certifying physician or allowed practitioner must have a face-to-face encounter assessment before they certify the beneficiary for home health care eligibility.

Resources:
5HD01

MR downcode/documentation contradicts OASIS M item(s).

Reference:
5HD02

MR downcode/provider billed higher category than OASIS M item(s) billed.

Reference:
5HD03

Partial denial for therapy resulting in MR down code.

· The assessment, measurement, and documentation of effectiveness wasn't completed at the required interval(s) or wasn't completed by a therapist. The 30-day reassessment was missing.

Reference:
5HD04

Partial denial resulting in a LUPA.

Reference:
5HD05

HIPPS reduced for non-routine supplies (NRS).

Reference:
5HDEM

Demand bill reversed and paid in part or in full.
5HH01

Documentation submitted does not support homebound status.

  • The beneficiary was noted per documentation to leave home frequently, without a taxing effort.

Reference:
5HH02

Homebound status not met due to ineligible place of residence.

Reference:
5HI01

Insufficient documentation of hours to determine if the part-time requirement is met.

Reference:
5HI02

Documentation does not support exemption from endpoint for daily insulin administration.

· Documentation doesn't support why the beneficiary couldn't self-inject insulin or that there wasn't a willing and able caregiver to perform administration.

Reference:
5HI03

These services are denied because the part-time or intermittent criteria aren't met. Skilled nursing care exceeds 28/35 hours.

Reference:
5HI04

These services are denied because the part-time or intermittent criteria aren't met. Home health aide care exceeds 28/35 hours.

Reference:
5HI05

Medicare will pay for daily skilled nursing care when the beneficiary needs daily care for a temporary, but not indefinite period. However, the physician must document the need for daily care and determine when daily care is realistically expected to end. Based on the medical information provided, these requirements were not met.

Reference:
5HI06

To qualify for Medicare home health services, the beneficiary needs to have intermittent skilled nursing care visits. When the medical need is only for a single skilled nursing visit, Medicare cannot pay for the nurse because the intermittent requirement is not met.

Reference:
5HN01

Skilled observation was not needed from the start of care (SOC).

Reference:
5HN02

Documentation does not support the medical necessity of additional teaching and/or training.

  • Skilled nurse notes indicate repetitive teaching.

Reference:
5HN03

Documentation does not support why medication can't be self-injected.

  • Documentation doesn't support why the beneficiary couldn't self-inject their medication or that there wasn't a willing and able caregiver to perform administration.

Reference:
5HN04

Documentation does not support that Epogen administration was medically necessary.

Reference:
5HN05

Documentation does not support why insulin can't be self-injected.

Reference:
5HN06

Vitamin B-12 is not reasonable and necessary based on diagnosis.

Reference:
5HN07

More skilled nursing visits were provided than medically necessary.

Reference:
5HN08

Documentation does not support that skilled management and evaluation (M&E) of care plan is reasonable and necessary.

Reference:
5HN09

Monthly mediport flush without administration of medication is not medically necessary.

Reference:
5HN10

Medicare requirements are that skilled observation is needed as long as the reasonable potential for change in condition exists. There was no further need for skilled observation.

Reference:
5HN11

Documentation does not support the frequency of venipunctures.

Reference:
5HN12

Documentation does not support more than one Vitamin B12 injection in the same month.

Reference:
5HN13

The Medicare program does not consider prefilling of insulin syringes to be a skilled nursing service.

Reference:
5HN14

Based on the documentation submitted, the type of medication received is not accepted by Medicare as an effective treatment for the medical condition.

Reference:
5HN15

Documentation does not support why the injectable medication could not be given orally.

Reference:
5HN16

Documentation does not support that wound care required the skills of a nurse.

Reference:
5HN17

Documentation does not support the medical necessity of catheter changes more frequently than once a month.

Reference:
5HN18

Skilled nursing services were not medically necessary.

  • Skilled nursing visits for general assessment, medication planner prefill/mgmt., repetitive teaching.

Resources:
5HO01

Medicare requires that all services be ordered by a physician. The denied visits were not ordered or exceeded the physician's orders.

Reference:
5HO02

The order(s) are incomplete as they must indicate discipline, frequency duration, and treatment.

Reference:
5HO03

Medicare requirements for Home Health require that physician order(s) must be received either verbally or in writing before delivery of the services. These orders must be signed prior to billing the services.

Reference:
5HO04

Medicare requirements for home health require that physician order(s) must be signed prior to billing the services.

Reference:
5HR01

No documentation of services rendered.
5HS01

The OASIS was not submitted to the repository and/or not submitted prior to billing the final claim.
Reference:
5HS02

Medical necessity not supported as an incorrect OASIS was submitted.

Reference:
5HU01

Based on medical review of the documentation, the HIPPS code has been recoded, resulting in a change to Medicare payment.

Reference:
5HW01

Information provided does not support the medical necessity for medical social worker visit(s).

Reference:
5HX01

Services for the sole purpose of evaluating the patient for the Medicare home health benefit are not considered billable visits.

Reference:
5HX02

A skilled nursing assessment visit for the sole purpose of admission is an administrative cost and is not billable.

Reference:
5HX03

Home health service(s) were billed in error.

Reference:
5HX04

Service(s) are not covered as the beneficiary was not home.

Reference:
5HX05

These services are denied as there was no qualifying skilled service provided.

Reference:
5HY01

The medical documentation submitted did not show that the therapy services were reasonable and necessary and at a level of complexity which requires the skills of a therapist.

Resources:
5HY02

The therapy documentation does not support that the Assessment, Measurement and Documentation of Therapy Effectiveness was completed at the required interval(s) and/or was not completed by a therapist.

(also see reason code 5HD03)

Reference:
5HZ01

Medicare can cover home health services only when intermittent skilled nursing care or physical or speech therapy is also needed. Since the beneficiary did not need these services, no payment can be made for the services listed.

Reference:

Updated: 07.08.2025

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved