Medicare Denied Home Health Care Claim

What This Means

If already-covered home health services are ending, act on the fast-appeal notice first. Your agency should give you a Notice of Medicare Non-Coverage (NOMNC). Request review from the independent reviewer listed on it: for Original Medicare, contact the BFCC-QIO by noon of the calendar day after receiving the notice; for Medicare Advantage, contact the Medicare-contracted reviewer by noon of the first day after notice delivery. This request goes to the reviewer, not just the agency or plan. Follow the notice’s instructions immediately and call the reviewer if its listed deadline appears inconsistent with when you received it. Ask your physician to explain whether stopping the services would put your health at significant risk. A late request can still be reviewed, but special decision timeframes and financial protections may be lost (Original Medicare rule; Medicare Advantage rule).

An ordinary claim or initial coverage denial follows a different route. If care was never approved, or the dispute is a processed claim rather than termination of ongoing covered services, follow the claim or plan denial notice. Original Medicare redetermination generally is due within 120 days after receiving the MSN, presumed received five days after its date unless shown otherwise. A Medicare Advantage appeal generally is due within 65 days of the denial notice date. Do not use those longer windows for a NOMNC fast appeal. On an MSN or EOB, a home-health claim denial may appear as CARC CO-50 (medical necessity) or CO-204 (service not covered under the current benefit plan).

Medicare covers home health care when you meet specific requirements. If Medicare (or your Medicare Advantage plan) decides you do not meet one or more of those requirements, your claim will be denied.

Why This Happens

Home health denials usually come down to one of these reasons:

• Medicare says you are not homebound. To qualify for home health, you must be “homebound” — meaning it takes a considerable and taxing effort to leave your home because of illness or injury (codified at 42 CFR 409.42 and detailed in CMS Medicare Benefit Policy Manual, Chapter 7). If your medical records do not clearly show why leaving home is difficult for you, the claim may be denied.
• The face-to-face encounter was missing or incomplete. Federal regulation 42 CFR 424.22(a)(1)(v) requires that your doctor (or certain nurse practitioners or physician assistants) see you in person before certifying your need for home health. This visit must happen no more than 90 days before or 30 days after the start of home health services. If the visit did not happen, was not documented properly, or was outside the allowed time window, the claim will be denied.
• Medicare says you do not need skilled care. Home health coverage requires that you need skilled nursing care, physical therapy, speech therapy, or occupational therapy. If Medicare decides your needs are not “skilled” — for example, if you only need help with bathing or meals — it may classify the care as custodial and deny coverage.
• The documentation does not support medical necessity. Even if you meet all the requirements, the claim can be denied if your medical records do not clearly explain why home health care is needed. Per CMS Comprehensive Error Rate Testing (CERT) data, insufficient documentation has consistently accounted for more than half of home health improper payments.
• Your Medicare Advantage plan denied prior authorization. MA plans may require pre-approval or use plan networks for home health, but they must follow applicable Traditional Medicare coverage criteria for basic benefits. Where Medicare criteria are not fully established, a plan may use publicly accessible internal criteria only within the limits of 42 CFR 422.101. Ask which rule the plan applied.

Should You Appeal?

What To Do Next

1. Identify the notice and protect the right deadline. If already-covered care is ending, get the NOMNC and contact its independent reviewer immediately using the fast-appeal timing above. If the dispute is an ordinary claim or initial coverage denial, follow that notice’s appeal instructions. Do not wait for the agency to finish a paperwork review before protecting either deadline.
2. Talk to your doctor. Ask for a statement supporting your homebound status and skilled-care needs. For an Original Medicare fast review of home health termination, also ask the physician to explain whether stopping the services would put your health at significant risk.
3. Check the face-to-face encounter. Ask your doctor’s office whether the face-to-face visit was completed and documented within the required time frame (90 days before or 30 days after the start of services). If it was not, your doctor may be able to complete it and the home health agency can resubmit.
4. Contact your home health agency. The agency’s staff can help you understand the denial and may assist with the appeal. They have experience with these issues and know what documentation Medicare requires.
5. Submit the supporting records through the correct review route. For a NOMNC termination, give the independent reviewer the clinical information it requests. For an ordinary claim denial, file with the Medicare contractor or plan identified on the notice within the applicable 120-day or 65-day window. Include relevant clinical notes, your doctor’s statement and face-to-face encounter documentation; a call to the agency does not replace a required appeal.
6. Get free help. Contact your State Health Insurance Assistance Program (SHIP) or call 1-800-MEDICARE (1-800-633-4227). The Center for Medicare Advocacy offers a free self-help packet for home health appeals.

Sources

• Medicare.gov: Home Health Services — beneficiary-facing summary of Medicare home health coverage and the homebound rule.
• 42 CFR 409.42: Beneficiary qualifications for coverage of services — regulatory homebound definition.
• 42 CFR 424.22: Requirements for home health services — the face-to-face encounter rule (90 days before / 30 days after start of care).
• CMS Medicare Benefit Policy Manual, Chapter 7 — CMS’s own detailed guidance on home health coverage, homebound criteria, and skilled-need requirements.
• CMS: Home Health Services Compliance Tips — provider-facing documentation requirements.
• CMS Comprehensive Error Rate Testing (CERT) — the program that measures and reports home health improper-payment causes.
• Center for Medicare Advocacy: Jimmo v. Sebelius / Improvement Standard — explanation of the maintenance-coverage protection.
• Center for Medicare Advocacy: Self-Help Packet for Home Health Appeals — step-by-step appeal guide.
• Center for Medicare Advocacy: Face-to-Face Encounter Requirement — patient-advocacy explainer on the F2F rule.
• X12: Claim Adjustment Reason Codes (CARCs) — official definitions of CO-50 and CO-204.
• 42 CFR 422.101: Medicare Advantage basic benefits — requires MA plans to follow applicable Traditional Medicare home-health coverage criteria.
• CMS: FFS and MA NOMNC/DENC — notices and independent fast review when covered home health services end.
• 42 CFR 405.1202 and 42 CFR 422.626 — receipt/delivery-based fast-appeal deadlines and late-request rules.

Frequently Asked Questions