Palmetto GBA: Service Specific Probe Review for Select HIPPS Codes

The J11 A/B MAC Medical Review department will perform a service-specific prepay complex review on claims billed for selected Home Health HIPPS codes.

The Medical Review department identified the top 20 Home Health HIPPS codes, ranked by provider disbursement. Information was contained within the reports regarding the number of claims medically reviewed, and the number of claims that contained a medical review denial. Further analysis determined a claim count denial rate for each of these HIPPS codes.

Palmetto GBA will be setting service-specific complex targeted medical review edits for the two HIPPS codes with the highest claim count denial rate: 2CGK* and 1BGP* (variable last digit of HIPPS Codes). These edits will be set for four regions within the J11 Home Health and Hospice jurisdiction.

These four regions are:

  • Midwest (Illinois, Indiana and Ohio)
  • Southeast (Kentucky, North Carolina, South Carolina and Tennessee)
  • Southwest (Arkansas, Louisiana, New Mexico, Oklahoma and Texas)
  • Gulf Coast (Alabama, Florida, Georgia and Mississippi)

Providers who receive an Additional Documentation Request (ADR) must submit the requested medical record information within 30 days to:

Palmetto GBA
J11 Part A Medical Review
Mail Code: AG-230
P.O. Box 100238
Columbia, SC 29202-3238

Or fax to (803) 699-2436.

When the claim is finalized, the claim will have paid in full or part, or denied. If you disagree with the decision, you may request a redetermination within 120 days of the determination (date on the remittance advice). 

Completed review results will be posted to the Palmetto GBA website. Individual providers with significant denials may be contacted for one-on-one education.

If a provider has a claim selected for this review and has questions regarding this Home Health HIPPS code review they may be directed to the Palmetto GBA J11 Home Health and Hospice Provider Contact Center at (866) 830-3925.

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