Hospice agencies billing Medicare are routinely subject to medical review requests to validate eligibility, medical necessity, and documentation compliance. One of the primary contractors issuing these requests is Noridian Healthcare Solutions, acting on behalf of the Centers for Medicare & Medicaid Services (CMS).
A Noridian medical record request is not simply administrative. It is a formal audit trigger that requires the hospice to demonstrate that the patient met hospice eligibility criteria and that all services were supported by compliant documentation. Improper or incomplete responses often result in claim denials and recoupments.
What Is a Noridian Medical Record Request?
Noridian issues medical record requests under several review programs, including:
Targeted Probe and Educate (TPE)
Additional Documentation Requests (ADR)
Post-payment review audits
These requests are typically triggered by:
The request will specify:
Hospices must respond within the specified timeframe to avoid automatic denial.
Scope of Hospice Record Review
Noridian evaluates whether hospice services met Medicare eligibility requirements under the hospice benefit. The review is comprehensive and focuses on the entire episode of care.
Key areas of review include:
Terminal prognosis (6 months or less)
Physician certification and narrative
Medical necessity for hospice level of care
Plan of care (POC) compliance
Interdisciplinary Group (IDG) involvement
Ongoing eligibility throughout benefit periods
The central question is: Did the patient meet and continue to meet hospice eligibility criteria?
Core Documentation Required
Certification of Terminal Illness (CTI)
The CTI is one of the most critical documents in hospice audits. It must clearly support a prognosis of six months or less.
Requirements include:
Signed and dated by physician
Completed within required timeframes
Includes a narrative explaining terminal prognosis
Narrative must be patient-specific and clinically supported
Generic or templated narratives are a leading cause of denial.
Physician Narrative
The physician narrative must explain why the patient is terminally ill, not just list diagnoses.
Strong narratives include:
Clinical indicators supporting decline
Disease progression details
Functional status changes
Supporting comorbidities
Narratives must be individualized and align with the clinical record.
Face-to-Face Encounter (F2F) for Recertification
For certain benefit periods, a face-to-face encounter is required.
Documentation must:
Occur within the required timeframe
Be performed by a qualified practitioner
Include clinical findings supporting continued eligibility
Be signed and dated
Missing or incomplete F2F documentation is a common denial trigger.
Clinical Documentation
Clinical documentation must support both initial and ongoing eligibility.
Key elements include:
Documentation must clearly show that the patient remains terminally ill.
Plan of Care (POC)
The POC must reflect individualized care and physician oversight.
Requirements include:
Physician approval and signature
Alignment with patient condition
Updates based on changes in status
Interdisciplinary coordination
Interdisciplinary Group (IDG) Documentation
IDG documentation must demonstrate active care coordination.
Records should show:
Common Denial Drivers
Noridian hospice reviews consistently identify similar patterns of noncompliance.
Frequent denial reasons include:
CTI narrative lacking clinical support
Missing or late physician certifications
Documentation does not support terminal prognosis
Lack of evidence of continued decline
Inconsistent documentation across disciplines
Failure to meet face-to-face requirements
These deficiencies often lead to denial of entire benefit periods.
High-Risk Hospice Scenarios
Certain patient cases are more likely to be audited.
High-risk scenarios include:
Long lengths of stay
Diagnoses with less predictable decline (e.g., dementia)
Minimal documented decline over time
Repetitive or templated documentation
Late recertifications
Hospices should monitor these cases closely.
How to Respond to a Noridian Request
A structured response process is critical to reduce denial risk. The goal is to present a clear, defensible clinical story.
Step-by-Step Response Approach
Review request immediately and note deadline
Identify all required documentation
Assign internal audit responsibility
Conduct full chart review before submission
Verify:
Organize records chronologically
Best Practices for Submission
Strong submissions improve audit outcomes and reduce misinterpretation.
Hospices should:
Submit a complete and organized record
Include a clinical summary explaining eligibility
Highlight key documentation supporting prognosis
Ensure consistency across all disciplines
Verify all signatures and dates
A clear and structured submission helps the reviewer understand the case.
Strategies to Reduce Audit Risk
Hospices must adopt proactive compliance strategies to minimize future audit exposure.
Effective strategies include:
Conduct routine hospice eligibility audits
Train physicians on narrative requirements
Strengthen documentation of decline
Ensure timely certifications and recertifications
Align IDG documentation with clinical record
Perform mock Noridian audits
Alignment with CMS Hospice Requirements
Noridian reviews are based on CMS hospice Conditions of Participation and coverage requirements. Hospices must ensure documentation aligns with these standards at all times.
Strong-performing agencies demonstrate:
Clear evidence of terminal prognosis
Consistent documentation of decline
Active physician involvement
Timely and accurate records
Effective quality assurance programs
Conclusion
Noridian hospice medical record requests require providers to fully support eligibility, medical necessity, and compliance with Medicare hospice requirements. The primary risk areas include physician narratives, certification timing, and documentation of decline.
Hospices that implement strong documentation systems, proactive audits, and structured response processes are best positioned to withstand medical review and reduce financial risk.
References
CMS Hospice Benefit Overview
https://www.cms.gov/medicare/coverage/hospice-benefit
Noridian Hospice Medical Review Resources
https://med.noridianmedicare.com/web/jddme/reviews
CMS Program Integrity Manual (Pub. 100-08)
https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf
Medicare Benefit Policy Manual – Hospice
https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c09.pdf
CMS Hospice Conditions of Participation
https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418
