Good Afternoon MFS Bloggers, I recently came across this very informative RHHI memo on transfers. Given the fact that CMS nor the RHHI has posted anything recently on the prevalent issue of patient transfers, I thought it would be a good idea to post a blog with the informaiton. Happy reading!!
What is a Transfer? A transfer is described as a single beneficiary choosing to change home health agencies (HHAs) during the same 60-day period. It is imperative that HHAs work together during a transfer situation.
Steps for the Receiving Home Health Agency:
• Check the Health Insurance Query for HHAs (HIQH) to determine if the beneficiary is currently under an established plan of care with another HHA.
• Document in the record that you accessed HIQH by printing and date stamping page 3.
o If the patient is under the care of another HHA:
• Contact the initial HHA to work out the transfer date.
• Document you contacted the other agency and include the name of the person you spoke with and the date and time of contact.
• Inform the beneficiary that the initial HHA will no longer receive Medicare payment on behalf of the patient and therefore will no longer provide Medicare covered services to the patient after the date of the patient's elected transfer. Document in the patient's file that the beneficiary was notified of the transfer criteria and the possible payment implications.
• Submit your Request for Anticipated Payment (RAP) with source of admission code 'B' to indicate transfer from another HHA.
Steps for the Initial Home Health Agency:•
Document the receiving agency contacted you to inform you of the beneficiary transfer and that you accepted the transfer.
• Include the name of the person you spoke with at the agency, date, time and date agreed upon for transfer to take place.
• Submit your final claim with Patient Status Code 06' to indicate transfer to another HHA.
What should you do if there is a dispute?
Should a dispute arise, both agencies should try to work out the issue between them prior to calling the Fiscal Intermediary. In the instance when a resolution cannot be made then the initial HHA should contact the Palmetto GBA Provider Contact Center at (866) 801-5301. Palmetto GBA will work with both agencies to settle the dispute however, certain information will need to be provided.
If the receiving HHA can provide documentation to support the bullets listed under Steps for the Receiving Home Health Agency above were completed, the initial HHA will not receive payment for the period of overlapping dates in addition to receiving the Partial Episode Payment (PEP) adjustment to their claim.
If the receiving agency cannot provide documentation to support an appropriate transfer was completed, the receiving agency's Request for Anticipated Payment (RAP) and/or Final Claim will be canceled and full payment will be made to the initial HHA.
NOTE: To obtain information in regards to Home Health Overlaps, please refer to the How to Avoid Overlapping Home Health Episodes job aid at www.PalmettbGBA.com/rhhi
Monday, September 20, 2010
Monday, September 13, 2010
HHA Prepayment Review Letters a/k/a Additional Development Requests
Good Afternoon MFS Bloggers, I have seen an influx of ADR letters recently coming from wither the RHHI or your local ZPIC's requesting medical records prior to adjudicating your caims for payment. The below information is taken from a recent CMS transmittal. Please follow these CMS instructions very carefully when responding to an ADDR letter as your cash flow depends upon your strict adherence.
Additional Development Requests (ADRs)
An ADR is a request from Palmetto GBA for copies of medical records for review purposes:
- A provider has 30 days to respond and submit documentation for review
- ADRs are mailed in a bright yellow envelope with ‘ADR Request Time Sensitive’ in red on the envelope.
- Submit the requested documentation to the address on the ADR using the appropriate mail code.
- It is suggested that the provider track an ADR from the time it is received/printed until the status/location SB6001
- To print a hardcopy ADR from DDE, select 01 ‘inquiries’. Press enter and select 12 for ‘Claims’ at the sub-menu. Press enter. Tab to the S/LOC field and type SB6001. All claims in this S/LOC will be reflected in the ‘Claim Summary Inquiry’ screen.
- Following medical review, if there is a difference on the Remittance Advice between the submitted charges and the agency’s payment, the provider can access the Remarks section to determine the reason for any denials/down codes of claim. At the DDE Main Menu, select 02. Press Enter. Select 26 and press enter. Enter page number ‘04’ and press enter. Medical Review remarks are located on page 04. If a review note is not available on this page, contact the PCC for assistance.
Good Luck!!! CP
Additional Development Requests (ADRs)
An ADR is a request from Palmetto GBA for copies of medical records for review purposes:
- A provider has 30 days to respond and submit documentation for review
- ADRs are mailed in a bright yellow envelope with ‘ADR Request Time Sensitive’ in red on the envelope.
- Submit the requested documentation to the address on the ADR using the appropriate mail code.
- It is suggested that the provider track an ADR from the time it is received/printed until the status/location SB6001
- To print a hardcopy ADR from DDE, select 01 ‘inquiries’. Press enter and select 12 for ‘Claims’ at the sub-menu. Press enter. Tab to the S/LOC field and type SB6001. All claims in this S/LOC will be reflected in the ‘Claim Summary Inquiry’ screen.
- Following medical review, if there is a difference on the Remittance Advice between the submitted charges and the agency’s payment, the provider can access the Remarks section to determine the reason for any denials/down codes of claim. At the DDE Main Menu, select 02. Press Enter. Select 26 and press enter. Enter page number ‘04’ and press enter. Medical Review remarks are located on page 04. If a review note is not available on this page, contact the PCC for assistance.
Good Luck!!! CP
Thursday, September 9, 2010
Expansion of Scope of Edits for Home Health Agencies
Good Morning MFS Bloggers, The following excerpt was taken from a recent CMS Transmittal. Happy reading!
Effective Date: October 1, 2010 (Phase 1); January 1, 2011 (Phase 2)
Provider Types Affected
This article is for free-standing and provider-based Home Health Agencies (HHAs) who bill Medicare Regional Home Health Intermediaries (RHHIs) for services provided to Medicare beneficiaries.
Background
The Centers for Medicare & Medicaid Services (CMS) is expanding claim editing to meet the Social Security Act requirements for the attending physician when a plan of treatment is needed and submitted from an HHA. In this document, the word ‘claim’ means both electronic and paper claims. The following are the only providers who can order/refer HHA beneficiary services:
- Doctor of medicine or osteopathy; and
- Doctor of podiatric medicine.
CMS claim editing is being expanded to verify that the attending physician on an HHA claim is eligible and is enrolled in Medicare’s PECOS. The editing expansion will be done in two phases:
• Phase 1 (October 1st, 2010 – December 31st, 2010) When a claim is received, CMS will determine if the attending physician is required for the billing service. If the attending physician’s NPI is on the claim, Medicare will verify that the attending physician is on the national PECOS file. If the attending physician NPI is not on the national PECOS file during Phase 1, the claim will continue to process but a message will be included on the remittance advice notifying the billing provider that claims may not be paid in the future if the attending physician is not enrolled in Medicare or if the attending physician is not of the specialty eligible to be an attending physician for HHA services.
• Phase 2 (On or after January 1, 2011) As stated above, Medicare will determine if the attending physician’s NPI is required for the billed service. If the billed service requires an attending physician and the attending physician’s NPI is not on the claim, the claim will not be paid. If the attending physician’s NPI is on the claim, Medicare will also verify that the attending physician is on the national PECOS file. If the attending physician is on the PECOS file, but not as specialty eligible to be an attending physician, the claim, during Phase 2, will not be paid.
Effective Date: October 1, 2010 (Phase 1); January 1, 2011 (Phase 2)
Provider Types Affected
This article is for free-standing and provider-based Home Health Agencies (HHAs) who bill Medicare Regional Home Health Intermediaries (RHHIs) for services provided to Medicare beneficiaries.
Background
The Centers for Medicare & Medicaid Services (CMS) is expanding claim editing to meet the Social Security Act requirements for the attending physician when a plan of treatment is needed and submitted from an HHA. In this document, the word ‘claim’ means both electronic and paper claims. The following are the only providers who can order/refer HHA beneficiary services:
- Doctor of medicine or osteopathy; and
- Doctor of podiatric medicine.
CMS claim editing is being expanded to verify that the attending physician on an HHA claim is eligible and is enrolled in Medicare’s PECOS. The editing expansion will be done in two phases:
• Phase 1 (October 1st, 2010 – December 31st, 2010) When a claim is received, CMS will determine if the attending physician is required for the billing service. If the attending physician’s NPI is on the claim, Medicare will verify that the attending physician is on the national PECOS file. If the attending physician NPI is not on the national PECOS file during Phase 1, the claim will continue to process but a message will be included on the remittance advice notifying the billing provider that claims may not be paid in the future if the attending physician is not enrolled in Medicare or if the attending physician is not of the specialty eligible to be an attending physician for HHA services.
• Phase 2 (On or after January 1, 2011) As stated above, Medicare will determine if the attending physician’s NPI is required for the billed service. If the billed service requires an attending physician and the attending physician’s NPI is not on the claim, the claim will not be paid. If the attending physician’s NPI is on the claim, Medicare will also verify that the attending physician is on the national PECOS file. If the attending physician is on the PECOS file, but not as specialty eligible to be an attending physician, the claim, during Phase 2, will not be paid.
Wednesday, September 1, 2010
Home Health Agencies (HHAs) Providing Durable Medical Equipment (DME) in Competitive Bidding Areas
Good Afternoon MFS Bloggers, If your agency is located or doing business in a competitive bidding area (CBA), please pay special attention to the CMS information posted below. This information will have profound effects on your DME revenue, if in fact you submit claims for DMEPOS for your hha beneficiaires. For those of you not currently located in a competitive bidding area, please take note as these restrictions will certainly effect your Agency once the competitive bidding program is expanded to your zip code.
Provider Types Affected
This article is for all HHAs submitting claims to Regional Home Health Intermediaries (RHHIs) for DME provided to Medicare beneficiaries residing in competitive bidding areas.
Provider Action Needed
The Centers for Medicare and Medicaid Services (CMS) issued Change Request (CR) 7014 to alert HHAs that edits will be in place, effective for services on or after January 1, 2011, to prevent HHAs from billing competitively bid DME items in competitive bidding areas and consequently preventing the in appropriate payment of competitively bid DME items to HHAs. Make certain your billing staffs are aware of these changes.
Background
Beginning January 1, 2011, in competitive bidding area, a supplier must be awarded a contract by Medicare in order to bill Medicare for competitively bid DME. Therefore, HHAs that furnish DME and are located in an area where DME items are subject to a competitive bidding program must either be awarded a contract to furnish these items in this area or use a contract supplier in the community to furnish these items. The competitive bidding items will be identified by HCPCS codes and the competitive bidding areas will be identified based on zip codes where beneficiaries receiving these items maintain their permanent residence. The DME MACs will have edits in place indicating which entities are eligible to bill for competitive bid for items and the appropriate competitive bid payment amount.
Key Points of CR 7014•
Your Medicare contractor will return HH claims (types of bill 32x, 33x and 34x) to you when such claims contain Healthcare Common Procedure Coding System (HCPCS) codes that are identified as being for items or services subject to competitive bidding in a competitive bidding areas.
• For your HHA to bill competitively bid items, your HHA must also be a contract supplier under Medicare’s DME competitive bidding program.
• Note: All suppliers for competitively bid DME must bill the DME Medicare Administrative Contractors (MAC) for these items and will no longer be allowed to bill for competitive bid items to Medicare contractors processing home health claims. Home health claims submitted for HCPCS codes are subject to a competitive bidding program will be returned to the provider to remove the affected DME line items.
• The applicable HCPCS codes and Zip Codes for the competitive bidding areas can be found on the “Supplier” page of the following Competitive Bid Implementation Contractor (CBIC) Web site at http://www.dmecompetitivebid.com/Palmetto/Cbic.nsf/DocsCat/Home on the internet.
• Claims for DME furnished by HHAs that are not subject to competitive bidding may still be submitted to the appropriate home health claims processing contractor.
Provider Types Affected
This article is for all HHAs submitting claims to Regional Home Health Intermediaries (RHHIs) for DME provided to Medicare beneficiaries residing in competitive bidding areas.
Provider Action Needed
The Centers for Medicare and Medicaid Services (CMS) issued Change Request (CR) 7014 to alert HHAs that edits will be in place, effective for services on or after January 1, 2011, to prevent HHAs from billing competitively bid DME items in competitive bidding areas and consequently preventing the in appropriate payment of competitively bid DME items to HHAs. Make certain your billing staffs are aware of these changes.
Background
Beginning January 1, 2011, in competitive bidding area, a supplier must be awarded a contract by Medicare in order to bill Medicare for competitively bid DME. Therefore, HHAs that furnish DME and are located in an area where DME items are subject to a competitive bidding program must either be awarded a contract to furnish these items in this area or use a contract supplier in the community to furnish these items. The competitive bidding items will be identified by HCPCS codes and the competitive bidding areas will be identified based on zip codes where beneficiaries receiving these items maintain their permanent residence. The DME MACs will have edits in place indicating which entities are eligible to bill for competitive bid for items and the appropriate competitive bid payment amount.
Key Points of CR 7014•
Your Medicare contractor will return HH claims (types of bill 32x, 33x and 34x) to you when such claims contain Healthcare Common Procedure Coding System (HCPCS) codes that are identified as being for items or services subject to competitive bidding in a competitive bidding areas.
• For your HHA to bill competitively bid items, your HHA must also be a contract supplier under Medicare’s DME competitive bidding program.
• Note: All suppliers for competitively bid DME must bill the DME Medicare Administrative Contractors (MAC) for these items and will no longer be allowed to bill for competitive bid items to Medicare contractors processing home health claims. Home health claims submitted for HCPCS codes are subject to a competitive bidding program will be returned to the provider to remove the affected DME line items.
• The applicable HCPCS codes and Zip Codes for the competitive bidding areas can be found on the “Supplier” page of the following Competitive Bid Implementation Contractor (CBIC) Web site at http://www.dmecompetitivebid.com/Palmetto/Cbic.nsf/DocsCat/Home on the internet.
• Claims for DME furnished by HHAs that are not subject to competitive bidding may still be submitted to the appropriate home health claims processing contractor.
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