Policy Manual sample

MDT Home Health Care Agency, Inc. MEDICARE DENIALS AND ADDITIONAL DOCUMENTATION REQUESTS (ADRs) PURPOSE: To delineate the process for reviewing and handling Medicare Additional Documentation Requests (ADRs/488s) and Medicare Denials POLICY: · Director of Nursing, Clinical Manager or designee will review all Medicare ADRs and Denials to identify documentation deficits and to develop a plan for prevention of the identified deficits in the future. · This review also determines whether a denial is appropriate to appeal. PROCEDURE: The Medicare ADR process is overseen by the Director of Nursing, Clinical Manager/designee and administrative staff who will complete the following steps: Print the ADR and denial reports weekly. Forward to the appropriate Manager/Clinical Supervisor the request or denial from the Fiscal Intermediary for review and analysis. Forward completed reviewed work from the clinical staff to the Intermediary. Maintain a record of all ADR/488 requests, copies of records forwarded to the fiscal intermediary, and denials of coverage. The Manager/Clinical Supervisor completes the following steps: · Reviews the patient care record and if needed, discusses the case with the appropriate staff. · Monitors staff compliance and counsels accordingly. · VP of Operations or designee will review the ADR/denial reports with the Director of Nursing, Clinical Manager and Manager of QI on a quarterly basis or more frequently if indicated. Quality Improvement staff develops an action plan based on trends in the report findings and reports to the designated committee. Denial appeals are performed according to the Medicare guidelines and are monitored by VP of Operations or Director of Nursing, Clinical Manager. All Additional Document Requests are processed and returned within 30 days as mandated by Medicare guidelines. Home Health Agency Overall Plan and Budget F-26