Review Reason Codes and Statements
CMS contractors medically review some claims (and prior authorizations) to ensure that payment is billed (or authorization requested) only for services that meet all Medicare rules. If the review results in a denied/non-affirmed decision, the review contractor provides a detailed denial/non-affirmed reason to the provider/supplier.
Historically, Medicare review contractors (Medicare Administrative Contractors, Recovery Audit Contractors and the Supplemental Medical Review Contractor) developed and maintained individual lists of denial reason codes and statements. If you deal with multiple CMS contractors, understanding the many denial codes and statements can be hard. In 2015 CMS began to standardize the reason codes and statements for certain services. As a result, providers experience more continuity and claim denials are easier to understand.
A new set of Generic Reason codes and statements for Part A, Part B and DME have been added and approved for use across all Prior Authorization (PA), Claim reviews (including pre-pay and post-pay) and Pre-Claim reviews. These generic statements encompass common statements currently in use that have been leveraged from existing statements.
We developed review reason codes and statements for:
- Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) (PDF)
- Non-Emergent Ambulance Transport (PDF)
- Non-Emergent Hyperbaric Oxygen (PDF)
- Home Health Services (PDF)
- Inpatient Rehabilitation Facilities (IRF)
- Generic Review Reason Codes and Statements (Part A) (PDF)
- Generic Review Reason Codes and Statements (Part B) (PDF)
- Generic Review Reason Codes and Statements (DME) (PDF)
We are working on review reason codes and statements for:
- Home Oxygen Therapy
- Home Blood Glucose Monitoring Supplies
- Continuous Positive Airway Pressure (CPAP) Devices
- Nebulizers and Nebulizer Medications
Please email PCG-ReviewStatements@cms.hhs.gov for suggesting a topic to be considered as our next set of standardized review result codes and statements.