HCAF: Proving Medical Necessity: Documentation, Recertification, and Submission Compliance for Medicare Payment (SN, OT, ST - 1.5)

Demonstrating and supporting medical necessity is not only essential for patient-centered care but also directly impacts submission compliance and affirmation rates under CMS’s Home Health Review Choice Demonstration (RCD). This session will provide providers with strategies to document, review, and communicate medical necessity effectively—reducing denials, improving affirmation rates, and ensuring compliance with Medicare payment requirements.

By the end of this session, participants will be able to:

• Clearly define Medicare’s requirements for medical necessity in the home health setting.

• Apply best practices for documenting and supporting medical necessity throughout the episode of care.

• Conduct effective internal QA reviews to identify and correct documentation gaps before submission.

• Strengthen compliance with the Review Choice Demonstration by linking documentation to affirmation success.

• Recognize and respond to recertification trends within their agency to ensure services remain justifiable.

•  Support medical necessity during recertification—including when it is appropriate to continue or discharge.

• Navigate difficult conversations with patients and families who desire ongoing services without meeting criteria.

• Identify the most common RCD denial reasons and apply strategies to avoid them.

• Understand the purpose and process of the Notice of Medicare Non-Coverage (NOMNC) and the Quality Improvement Organization (QIO) appeal process.

Speakers/Course Authors - J'non Griffin & Kimberly Wilkerson