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Hospice 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 5PM01 According to Medicare hospice requirements, the information provided doesn't support a terminal prognosis of six months or less. 1061 53%
2 5PX06 The notice of election is invalid because it doesn't meet statutory or regulatory requirements. 649 33%
3 5PC08 Face-to-face encounter requirements aren't met. 66 3%
4 56900 Medical records weren't received timely. 50 3%
5 5PC01 A physician narrative is missing or invalid. 41 2%

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:
5PC01

The physician narrative statement was not present or was not valid.

  • The physician narrative statement wasn't present.
  • The physician narrative statement doesn't support a life expectancy of six months or less or was signed before the face-to-face encounter.
  • The physician narrative statement doesn't include a valid attestation statement.

Resources:
5PC02

No certification present in the documentation submitted for the dates billed.

Reference:
5PC03

Initial certification not signed by physician(s).

  • The designated attending or certifying physician signature is missing.

Reference:
5PC04

Subsequent certification not signed by physician.

Reference:
5PC05

Initial certification not signed timely by physician(s).

  • The designated attending or certifying physician signature isn't timely.

Reference:
5PC06

Subsequent certification not signed timely by physician.

Reference:
5PC07

Certification does not include the 6-month terminal prognosis statement.

  • Initial or subsequent certification doesn't include the 6-month terminal prognosis statement.

Reference:
5PC08

Face-to-Face encounter requirements not met.

  • Face-to-Face encounter didn't occur within required timeframes.
  • There was no valid attestation statement.

Resources:
5PC09

The hospice plan of care does not meet the requirements set forth in the code of federal regulations.

  • The hospice plan of care is missing or doesn't meet the code of federal regulations requirements.

Reference:
5PC10

According to Medicare Hospice requirements, the hospice must obtain, no later than 2 calendar days after hospice care is initiated, oral or written certification of the terminal illness by the medical director of the hospice and the individual's attending physician if so designated.

  • There is no verbal order and the physician signature date is after the billing period reviewed.

Reference:
5PD01

According to Medicare hospice requirements, physician services performed by a nurse practitioner should be billed with a GV modifier.

References:
5PM01

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

Resources:
5PM02

According to Medicare hospice requirements, the documentation indicates the general inpatient level of care was not reasonable and necessary. Therefore, payment will be adjusted to the routine home care rate.

Reference:
5PM03

According to Medicare hospice requirements, the documentation indicates the level of care was at the respite level of care, not at the general inpatient level of care. Therefore, payment will be adjusted to the respite care rate.

  • The payment changed to the respite level of care rate because the documentation indicates the general inpatient level of care wasn't reasonable and necessary.

Reference:
5PM04

According to Medicare hospice requirements, the documentation does not support that the requirements for respite care were met. Therefore, payment will be adjusted to the routine home care rate.

Reference:
5PM05

According to Medicare hospice requirements, the documentation indicates that the continuous home care was not reasonable and necessary. Therefore, payment will be adjusted to the routine home care rate.

  • Fewer than 8 hours of care during a 24-hour day.
  • The care wasn't predominately nursing care.
  • Care provided after the patient expired.

Reference:
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.

  • Documentation is missing or doesn't support that the physician services were reasonable and necessary.

Reference:
5PX01

Some of the continuous care hours billed were not documented in the submitted medical record.

Reference:
5PX03

According to Medicare hospice requirements, the documentation indicates the inpatient respite care exceeded five days. Respite days greater than 5 are paid at the routine home care rate.

Reference:
5PX06

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

Requirements include:

  • Identification of the hospice providing care to the beneficiary.
  • Notifying the beneficiary that care is palliative versus curative.
  • Notifying the beneficiary that certain Medicare services are waived by this election.
  • The date of the election.
  • The beneficiary's or representative's signature.
  • The designated attending physician is listed on the election.
  • The designated attending physician was the beneficiary's  or representative's choice.

Resources:
5PX07

The notice of election for this beneficiary was not received as requested.

Reference:

Updated: 07.08.2025

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