Policy Manual sample

MDT Home Health Care Agency, Inc. Services must be sufficiently described so that the beneficiary understands precisely what services may not be furnished (e.g., physical therapy services 4 times weekly). In the third blank (''because _________”), give the specific reason you expect Medicare to deny payment, The reason must be sufficiently specific to allow the beneficiary to understand the basis for denial of payment, and, if necessary, to gather evidence to the contrary from a physician and/or others in support of coverage (e.g. ''our clinical assessment of your condition indicates that you can benefit from physical therapy services twice weekly, but that additional physical therapy services each week would not be effective"). 8. In the blank, Ve estimate that all of those services will cost about $ ______”, enter estimated cost of the services (Use Public Charges). 9. Beneficiary must choose an option: A, B or C check box. In box A fill in other insurance for patient if necessary. 10. Have patient sign and date the ABN. Home Health Agency Policies A-128