Home health services were denied or stopped. How do I appeal?
Home health denials usually turn on whether skilled nursing or therapy is still needed, whether the patient is homebound, and whether the plan says goals have plateaued. Appeal with the plan of care, homebound documentation, skilled-need notes, and if you received a NOMNC, request the fast-track review before the cutoff.
What to do, in order
- Step 1
Find whether this is a start denial or a termination
A denial of new home health goes through the plan appeal process; a termination notice may have a fast-track appeal path.
- Step 2
Document homebound status and skilled need
Show why leaving home requires taxing effort and what skilled nursing or therapy is still needed.
- Step 3
Get the plan of care
The physician-certified plan of care, visit notes, and therapist progress notes should answer the criteria.
- Step 4
Request fast-track appeal if services are ending
For Medicare-related notices, call the QIO by the deadline on the notice and ask the agency to send the file.
The deadline that applies
Fast-track service-termination appeals follow the deadline on the NOMNC, generally no later than noon of the day before coverage ends (42 CFR 405.1200-405.1206; 42 CFR 422.626). Other denials use the plan appeal deadline, at least 180 days on employer and ACA plans.
Calculate your date →Documents to gather
- NOMNC or denial letter
- Home health plan of care
- Visit notes and therapy notes
- Homebound documentation
- Physician statement
Go deeper
Related questions
Does home health require improvement?
Not always. Skilled services may be covered to maintain function or prevent deterioration when the patient needs skilled care.
What if the patient is not strictly bedbound?
Homebound does not mean bedbound. The question is whether leaving home requires considerable and taxing effort.
Who sends records to the QIO?
The home health agency or plan must provide the record, but you should also keep a copy of the plan of care and notes.
Sources
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