Types of Denial Determinations - (Rev. 4, 07-18-03)

7101 - Types of Denial Determinations - (Rev. 4, 07-18-03) Initial and technical denials apply to services/items furnished in acute/specialty hospitals (including swing beds) and hospital outpatient/ambulatory surgical centers, hereafter referred to as providers. A. Initial Denials Initial denial determinations are subject to reconsideration and further appeals. These types of denials include:  Preadmissions;  Admission;  Continued-stay;  Circumvention of PPS;  Services/procedures; and  Cost outliers (and day outliers, if applicable). NOTE: Render an initial denial determination only after you have afforded the provider/practitioner an opportunity for discussion. B. Technical Denials Technical denial determinations are not subject to reconsideration and further appeals, but may be subject to re-review/reopening (See §7102.B). These types of denials include:  Medical record not submitted timely (42 CFR 476.90(b)); and  Billing errors (including cost outlier denials due to duplicative billing for services or for services not actually furnished or not ordered by the physician). NOTE: Opportunity for discussion does not apply to technical denials. C. DRG Assignment Changes The DRG assignment changes may result from your correction of technical coding errors or your correction of diagnostic, procedure, or discharge status information and the related codes. Changes to the DRG coding information are not subject to reconsideration and further appeals. These changes are, however, subject to re-review/reopening when they result in a revised DRG assignment and lower payment (See 42 CFR 478.15 and 478.48). NOTE: Render DRG assignment changes only after you have afforded the provider/practitioner an opportunity for discussion.