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Top Claims Denial Reasons from MACs

    Knowing the top claims denial reasons from Medicare Administrative Contractors (MACs) is helpful for home health agencies aiming to maintain financial stability and ensure timely reimbursement. By identifying and addressing the root causes of denials, providers can improve their billing and coding practices, optimize cash flow, and ultimately enhance patient care.

    Rectifying denied claims is a time-consuming and resource-intensive process. Additionally, claim denials can trigger additional development requests (ADRs) from the Centers for Medicare & Medicaid (CMS) as part of their quality control and payment verification measures. Proactively avoiding common issues in claims not only reduces the likelihood of ADRs but also helps ensure survey readiness.

    Below are the top claims denial reasons from the MACs:


    • Skilled nursing services not deemed medically necessary
    • Missing, incomplete, or invalid initial certification leading to denied recertification episode
    • Missing, incomplete, or untimely face-to-face encounters leading to denied physician certification
    • Insufficient medical documentation to show the necessity of therapy services
    • Missing signatures on a physician or allowed practitioner’s plan of care and/or certification


    • Not meeting face-to-face encounter requirements
    • Failure to submit requested records
    • No plan of care or certification
    • Lack of supporting information for the medical necessity of a service
    • No physician’s orders for services


    • No response from requests for medical records
    • Missing, incomplete, or invalid certification
    • Skilled nursing services not deemed medically necessary
    • Not meeting daily care requirements

    Preventing Future Setbacks with Proactive Measures

    Your QA program plays an important role in ensuring that key information is available, accurate, and consistent across all documentation to support claims and reduce the possibility of ADRs. 

    Furthermore, ensuring the accuracy of diagnosis coding on claim forms is also crucial, particularly in light of the Patient-Driven Groupings Model (PDGM) guidelines on the relevance of face-to-face encounter documentation with primary diagnosis coding. Healthcare providers must have a thorough understanding of the coding aspects of documentation not only to avoid claim denials but also to maximize reimbursement potential.

    In summary, a robust QA program combined with accurate diagnosis coding can help home health providers establish a proactive approach to maintaining documentation compliance, reduce the risk of denials or delays in reimbursement, and ultimately provide better patient care.