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Last Modified: 1/17/2025 Location: FL, PR, USVI Business: Part A

Skilled Nursing Facility (SNF) 5-Claim Probe and Educate (PE) Round Results

SNF 5-Claim PE

Top denial/partial denial reasons and high-level results are listed below from each round of SNF P&E services reviews that have been conducted thus far by Medical Review. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information. Additional rounds of review will be utilized when the targeted topic demonstrates a continued need for review with newly identified providers.

July 2023 – December 2023 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
2. Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
• Documentation submitted for review did not support a 3-day qualifying stay.
• Documentation submitted for review lacked days of coverage due to benefit exhaust.
• Documentation submitted for review lacked a certification or recertification signed timely.

Results

August 2023 - January 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
3. Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
• Documentation submitted for review did not support a 3-day qualifying stay.
• Documentation submitted for review did not support the services billed.

Results

September 2023 - February 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
4. Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
• Documentation submitted for review did not support a 3-day qualifying stay.
• Documentation submitted for review lacked a certification or recertification signed timely.
• Documentation submitted for review did not support the services billed.
• Non-response to documentation request.

Results

October 2023 - April 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
5. Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
• Documentation submitted for review did not support a 3-day qualifying stay.
• Documentation submitted for review did not support the services billed.

Results

November 2023 - May 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
• Documentation submitted for review did not support a 3-day qualifying stay.
• Documentation submitted for review did not support the services billed.

Results

December 2023 - June 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
• Documentation submitted for review did not support a 3-day qualifying stay.
• Documentation submitted for review lacked days of coverage due to benefit exhaust.
• Documentation submitted for review lacked a certification or recertification signed timely.
• Documentation submitted for review did not support the services billed.

Results

March 2024 - July 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
• Documentation submitted for review did not support a 3-day qualifying stay.
• Documentation submitted for review did not support the services bill\ed.
• Documentation submitted for review did not include the required certification/re-certification for the SNF stay.

Results

May 2024 - July 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
§ No denials

Results

January 2024 – August 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
a. Documentation submitted for review did not support a 3-day qualifying stay.
b. Documentation submitted for review did not support the services bill\ed.
c. Documentation submitted did not support the HIPPS code submitted to the repository, claim recoded to support the correct service.
d. Documentation submitted did not support the number of days billed, claim reduced to support the correct number of services.
e. Non-response to documentation request.

Results

June 2024 – September 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
2. Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
§ No denials

Results

August 2024 – November 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
2. Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
§ No denials

Results

February 2024 – December 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
2. Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
• Documentation submitted for review did not support the services billed.
• Non-response to documentation requested.

Results

September 2024 – December 2024 Top denial/partial denial reasons:

The most common reasons for denial or partial denials are the following:
1. Medical Necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
2. Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
• Documentation submitted for review did not support the services billed.

Results

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.