General
Answer: Federal regulations require that Medicare fee-for-service contractors maintain payment responsibility for managed care enrollees who elect hospice; specifically, regulations at 42CFR Part 417, Subpart P, 42 CFR 417.585 Special Rules: Hospice Care (b), and 42 CFR 417.531 Hospice Care Services (b). eCFR :: 42 CFR 417.585 -- Special rules: Hospice care.
While a hospice election is in effect, certain types of claims may be submitted to the MAC by either the hospice provider or a provider treating an illness not related to the terminal condition. The claims are subject to Medicare rules of payment.
- Hospice services covered under the Medicare hospice benefit are billed by the Medicare hospice.
- Institutional provider types may submit claims to Medicare with the condition code "07" when services provided are not related to the treatment of the terminal condition.
- Medicare Advantage plan enrollees that elect hospice may revoke hospice election at any time, but claims will continue to be paid by the MAC as if the beneficiary were enrolled in Medicare until the first day of the month following the date hospice election was revoked.
2. Our agency is suddenly receiving multiple remittance advises for claims with an 32I type of bill (TOB). No one in the facility is claiming responsibility for the submission of these claims. Are these claims legitimate or does my facility need to request an investigation?
Answer: There is no need to launch an investigation as the 32I type of bill is valid. When your staff sees claims with that bill type it indicates that the MAC initiated the claim adjustment. Common reasons that 32Is occur include:
- During the quarterly reconciliation process that occurs when an outlier, which was previously unpayable because it exceeded 10 percent of the HHA's total Home Health Prospective Payment System (HH PPS) payments, is now payable due to the subsequent processing of HH PPS claims over the calendar year.
- There has been an error identified in previous processing that facilitates the need for the MAC to adjust claim on behalf of the provider community.
More information can be found in Publication 100-04 Chapter 10 Sections 10.1.21 and 70.4 regarding MAC initiated adjustment bill types such as TOB 32I.
3. Where can my agency find detailed information on how to successfully respond to Additional Documentation Request if we are in a state that is involved in the Review Choice Demonstration (RCD)?
Answer: The Palmetto GBA website is a great tool to find out a magnitude of information regarding RCD including appropriately responding the ADR’s received.
The checklist can be found using the link Responding to Home Health Additional Documentation Request (ADR) Checklist (PDF). Be sure to follow all the instructions on the ADR to ensure you are providing the information being requested and send to the correct address.
Additional information regarding RCD can be found at: Understanding ADRs When Participating in the RCD and by clicking on the Home Health Review Choice Demonstration (RCD) webpage. It contains information such as Frequently Asked Questions , Educational Resources and Pre-Claim Review (PCR) information.
4. My agency is receiving Comprehensive Error Rate Testing(CERT) denials stating the signature requirements are not valid on previously processed claims. What information is available to my staff to avoid this from happening in the future?
Answer: The information found in CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3 Section 3.3.2.4 (PDF) describes what meets the signature requirements to avoid receiving related denials. “For medical review purposes, Medicare requires that the person(s) responsible for the care of the beneficiary, including providing/ordering/certifying items/services for the beneficiary, be identifiable as such in accordance with Medicare billing and coverage policies, such as the Social Security Act §1815(a) and §1833(e). Medicare contractors shall consider the totality of the medical record when reviewing for compliance with the above.
Signatures are required upon medical review for two distinct purposes:
- To satisfy specific signature requirements in statute, regulation, national coverage determination (NCD) or local coverage determination (LCD); and
- To resolve authenticity concerns related to legitimacy or falsity of the documentation.
5. Our agency is looking for information regarding the new benefit for Mental Health Counselor for beneficiaries enrolled in a hospice. Where can this information be located so that members of staff can be educated?
Answer: The Consolidated Appropriations Act of 2023 (Pub. L. 117–328) (CAA, 2023), was signed into law on December 29, 2022. Division FF, Section 4121 of the CAA, 2023 (PDF) which established new benefit categories. One of those new benefits were for Mental Health Counselor (NHC) services furnished by and directly billed by the MHC.
Section 4121(b)(2) of the CAA, 2023 (PDF) specifically adds these services to covered hospice care services under Section 1861(dd)(2)(B)(i)(III) of the Act.
The CAA, 2023 revised section 1861(dd) of the Act to state that the hospice interdisciplinary group (IDG) is required to include one social worker, MFT, or MHC.
To implement Division FF, section 4121 of the CAA, 2023, in the CY 2024 Physician Fee Schedule final rule CMS finalized changes to the regulations at §§ 418.56 and §§ 418.114 to permit MFTs or MHCs to serve as members of the hospice IDG.
Additional useful resources regarding this topic can be found using the following links:
Answer: A PHE declaration lasts until the Secretary of Health and Human Services declares that the PHE no longer exists or upon the expiration of the 90-day period beginning on the date the Secretary declared a PHE exists, whichever occurs first. The Secretary may extend the PHE declaration for subsequent 90-day periods for as long as the PHE continues to exist and may terminate the declaration whenever the Secretary determines that the PHE has ceased to exist. The declaration was most recently extended on July 15, 2022.
Palmetto GBA provides directions received from CMS on the Palmetto GBA website and through email update messaging. More questions and answers regarding the PHE are available on the U.S. Department of Health and Human Services Public Health Emergency Declaration Q&A web page.
Last Reviewed: 12/19/2024
Answer: The Internet-Only Manual (IOM) System on the CMS website houses the home health and hospice manual information. Please select the following manual references for home health and hospice billing and coverage information. When viewing this information, please select the appropriate provider type to view CMS guidelines.
- Introduction — Publication 100 (PDF)
- Coverage Information: Medicare Benefit Policy Manual — Publication 100-02
- Billing Information: Medicare Claims Processing Manual — Publication 100-04
Last Reviewed: 12/19/2024
Answer: You can’t adjust a claim to correct a medically denied line. You must submit a Redetermination: 1st Level Appeal form along with a corrected claim.
Last Reviewed: 12/19/2024
Answer: A PTAN is the Provider Transaction Access Number, which is also known as the six-digit provider number, OSCAR number or legacy number. Providers will be asked for their PTAN when calling the provider contact center (PCC).
Last Reviewed: 12/19/2024