Review Choice Demonstration Non-Affirmations and Denials: Appeals and Options

While the goal of submitting claims in the Review Choice Demonstration (RCD) project is to obtain provisional affirmation or payment, not all claims may end up achieving this status. At that time the home health agency is faced with a choice of what to do with the claim: write it off as non-billable or appeal and seek payment. Even with the unlimited ability for resubmission under Pre-Claim Review (Choice 1), some claims will not achieve a provisional affirmation status. If the home health agency feels strongly that their claim is valid and there was a demonstrated skilled need for the provision of home health services, submitting the claim for final billing will generate an automatic denial. And for the Additional Development Request (ADR) pre-payment (Choice 2 and Choice 5) and post-payment (Choice 4) options, an unfavorable decision only gives one option to obtain payment: appeal the denial.

This presentation provides an overview of the RCD choices, agency options for a non-affirmed or denied claim, and preventive measures that minimize the chances of an unfavorable RCD claim submission. This uses common denial reasons (applicable to the ADR choices) and non-affirmation reasons (for pre-claim reviews) and addresses how to prevent these for a smoother RCD experience. The process for filing appeals is also covered. Other areas covered include physician face-to-face (F2F) issues, certification deficiencies, and the most common medical necessity denials, including therapy documentation. A thorough walk-through of F2F encounter requirements and how the F2F content links with the Patient-Driven Groupings Model (PDGM) payment and possible denials or non-affirmations is covered. How these are applied to appeals for denied claims will also be reviewed.