What Documents are Needed?

You are required to submit all necessary medical documentation to support the services billed on your claim as part of your participation agreement; you must submit a complete medical record when requesting an appeal. If documentation was previously submitted to the Medical Review Department or another contractor, for example the Recovery Auditor (RA), CERT or PSC, those medical records will be included in the file reviewed by the Appeals department. 

Keep reading to learn the types of services you may appeal, as well as a list of medical records that may assist in supporting that the services billed are coverable by Medicare.

Home Health

• OASIS form for the dates of service in question
• Face-to-face encounter document
• Current home health certification and plan of care (appropriately signed and dated by doctor and nurse; and/or the receipt date from agency as needed)
• Any additional MD orders for the date of service in question, signed and dated by the doctor
• Therapy initial evaluation, reevaluations, and treatment visit notes for previous month and date of service in question
• Skilled nursing visit notes for previous month and date of service in question
• Social worker notes as applicable
• Home health aide visit notes for date of service in question
• ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services
• Records such as orders, clinic notes, discharge summary, from the MD
• office, hospital, or skilled nursing facility may be submitted to support the home health services were reasonable and necessary
• Laboratory test results if needed to support criteria met for medication such as Epogen and Aranesp per the local coverage determination
• Records to support patient has applicable diagnosis for medication such as Epogen, Aranesp, or Vitamin B-12

Hospice

• Initial certification, dually signed by the hospice MD director and primary MD supporting terminal diagnosis (six months or less)
• Recertifications (if appropriate) for the date of service under review
• NOE statements applicable to the dates of service
• Face-to-face encounter document
• Physician, nurse, and supporting personnel notes to support the criteria for determining terminal prognosis were met, to determine if the correct level of care were met, and to support the routine, continuous, general inpatient, or physician services billed
• ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary