Corporate

Hospice Top Medical Review Denial Reason Codes

January – March 2019

The following information provides hospice medical review denial data related to the most recent calendar quarter. Please review this information and the educational resources to assist with preventing these types of denials. Refer to the Hospice Denial Reason Codes Web page for a complete list of denial codes.

Rank Denial Code Denial Description # of Claims Denied % of Claims Denied

1

5PM01

According to Medicare hospice requirements, the information provided does not support a terminal prognosis of six months or less.

36

59%

Resources:

Rank Denial Code Denial Description # of Claims Denied % of Claims Denied

2

5PM07

According to Medicare Hospice requirements, the physician services were not reasonable and necessary or were administrative in nature including review, supervision and update of the care and services noted in the hospice care plan.

7

11%

Resources:

Rank Denial Code Denial Description # of Claims Denied % of Claims Denied

3

5PC08

Face-to-Face Encounter requirements not met.

6

10%

Resources:

Rank Denial Code Denial Description # of Claims Denied % of Claims Denied

4

5PX06

The notice of election is invalid because it doesn't meet statutory/regulatory requirements.

4

7%

Resources:

Updated: 04.23.19

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