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August 18, 2017

Resource Utilization Group (RUG) Codes RUA, RUB and RUC: Complex Review - Kentucky and Ohio –  Continue

The J15 Part A Medical Review department performed a service-specific complex review of Resource Utilization Group (RUG) Codes  RUA, RUB and RUC in Kentucky and Ohio from April through June 2017. Based on the results summarized below, the complex review was continued in Kentucky and Ohio. 

Kentucky Complex Edit Results:










Charge Denial Rate



Ohio Complex Edit Results:










Charge Denial Rate



The top denial reasons associated with this review:

5D504/5H504 – Information Provided Does Not Support the Medical Necessity for this Service

56900 – Medical Records Not Submitted

  • Reason for Denial:
    • Medical records were not received in response to an Additional Documentation Request (ADR) within the required time frame; therefore, we were unable to determine medical necessity.
  • How to Avoid a Denial:
    • Monitor your claim status in Direct Data Entry (DDE). Claims in status/location SB6001 have been selected for review by CGS and records must be submitted. Please note: CGS may request records through our Medical Review or Claims departments and other contractors, such as the Zone Program Integrity Contractor (ZPIC), may also request records that do not appear in the SB6001 location.  Ensure the records are submitted to the appropriate entity.
    • Ensure your mail room staff routes any mail you receive from CGS to the appropriate department for handling.
    • Submit medical records as soon as the ADR is received, but no later than 45 days of the date in the upper left corner of the ADR letter.
    • Gather all information needed for the claim and submit it all at one time.
    • Attach a copy of the ADR letter to each individual claim.
    • If responding to multiple ADRs, separate each response and attach a copy of the ADR letter to each individual set of medical records. Ensure 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 indicated in the ADR letter.
  • Options for Submitting Records:
    • Compact disks (CDs) or digital video disks (DVDs) – You must use the correct file format of tagged image file format (tiff), which may be saved to your CD/DVD.
    • Fax to: 803.462.2596 – Use the ADR letter as a cover sheet.
    • If you choose to respond by mail, send the requested records to the address indicated in the ADR letter.
    • myCGS web portal

5D505/5H505 – Certification Not Valid

  • Reason for Denial:
    • The certification or recertification for SNF admission was either not submitted for review or did not meet requirements for certification.
  • How to Avoid a Denial:
    • Ensure that the certification or recertification has been included in the submitted documentation request.
    • To meet requirements, the certification statement must clearly indicate post-hospital extended care services were required because of the individual’s need for skilled care on a continuing basis for which he/she was receiving inpatient hospital services.
    • The certification must be signed by an attending physician or physician on staff at the skilled nursing facility who has knowledge of the case, or by a nurse practitioner (NP), clinical nurse specialist (CNS) or physician assistant (PA) who is working in collaboration with the physician in charge of the individual’s care.
    • The initial certification should be made at the time of admission, or as soon therafter as is reasonable and practicable.
    • Must include the estimated period of time required for the beneficiary to remain in the facility and any plans (if appropriate) for home care.
    • If the circumstances require it, rescertifications must state that the need for continued skilled care is for a condition that occurred after the transfer from the hospital and while the beneficiary was still in the facility for treatment of the condition(s) for which he/she had received inpatient hospital services.
  • For additional information, please reference:

Individual providers with significant denials will be contacted for one-on-one education.

If you have any questions regarding this review, please contact the CGS Part A Provider Contact Center at 866.590.6703.

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