Ask-the-Contractor (ACT) Questions and Answers
February 18, 2015, "CR 8877: Updates from CGS on Timely Filing of NOEs and Exception Requests" ACT
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General
NOEs
- To ensure the NOE is timely, does CGS recommend that we continue to check the status of an NOE until we see it move from an 'S' to 'P' status?
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Yes, CGS recommends monitoring the status of an NOE as frequently as once a day. When an NOE is in an "S" status, it is still processing and there is the potential for it to be returned if an error is identified.
Reviewed: 09.26.16
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- A patient has a commercial insurance, and the hospice was paid by that insurance. Then, a month or two later the patient notifies the hospice they have Medicare benefits. Does the NOE have to be timely in those cases also?
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Yes, NOEs must be timely in these situations. An exception could be requested in this case, however, the hospice would need to show that they were not aware of the patient's Medicare entitlement at the time of election (i.e. beyond the hospice's control) in order for the exception to be granted. Note: CMS provided further direction regarding an individual who receives retroactive Medicare entitlment. A retroactive Medicare entitlement qualifies as one of the exceptions if a hospice NOE is not filed timely. However, the exception will only be granted with supporting documentation. Refer to the "Requesting an Exception" section found on the "Requesting an Exception for an Untimely NOE" CGS Web page.
Reviewed: 09.26.16
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- Are NOEs required in MSP situations? Example – Patient is covered by an Employer Group Health Plan (EGHP), but also has Medicare as a secondary payer. We have to bill Medicare as zero expected payment for all months the patient is on service with hospice even though we may not actually require payment from Medicare until a copay is applied or coverage is denied by the EGHP.
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With MSP, the NOE should still be submitted with Medicare as primary. NOEs are not edited for MSP. You still need to bill the primary insurer as you would normally, and when you bill your claims, you will still need to report the primary insurer information on your Medicare hospice claims. If you know a beneficiary has Medicare as secondary, comply with Medicare rules as if Medicare is primary. In the past, we have had cases where the primary insurer later comes back retroactively and says they were not primary, and there was no notice of election on file. In these cases, providers run into issues with noncompliance with Medicare regulations. Therefore, we recommend that when a beneficiary has Medicare as a secondary payer, you comply with all Medicare rules.
Reviewed: 09.26.16
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- An NOE was filed timely within the 5 day limit, but RTPd due to another hospice open benefit period. A new 81A was keyed instead of F'9 the original RTPd NOE and the new NOE paid but was past the 5 day limit. Can we cancel the second NOE with an 81D and then appeal for an exception with the screen print of the original 81A that was in an RTP status but that was just F9d after the 81D paid?
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In cases where an NOE is RTPd due to a prior open hospice benefit period, the initial NOE should be resubmitted (F9d) when the prior benefit period is termed. This helps maintain the audit trail of the original NOE, and helps support the hospice's case that the NOE was timely, but RTPd because of the open benefit period. While each exception request is reviewed and considered individually, we cannot guarantee that an exception request would be granted if a new NOE was submitted, instead of correcting the initial NOE. The documentation for the exception request must show that the untimely NOE was beyond the control of the hospice.
Reviewed: 09.26.16
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- A hospice has submitted a NOE timely, but it is RTPd back to the provider due to a prior open hospice election period. Once the prior benefit period is termed, the provider resubmits (F9s) the NOE, and the NOE receives a new receipt date. Is the original receipt date stored anywhere on or within that NOE so the MAC can still see the date the provider first submitted it? Or must providers solely rely on screen prints and documentation to support the evidence that they initially filed the NOE timely?
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The MACs have access to the original date the NOE was submitted, and the date it was F9d. However, it is recommended that the provider take a screenprint of the NOE, showing the initial receipt date and the reason code it hit (indicating an overlap situation). This information will assist CGS during the review process, and will help support the exception request.
Reviewed: 09.26.16
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- When an NOE was submitted, and we go back into FISS to verify submission of the NOE, we cannot find it. Is CGS aware of this? We have had this happen a hand full of times.
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This can occur when an NOE is submitted with an incorrect NPI number, an incorrect HICN, or an incorrect type of bill. Providers should verify the beneficiary's HICN using one of the eligibility systems. Providers should also verify that the NPI number and type of bill are entered correctly. CGS recommends that providers use FISS Option 12 (Claim Summary), and enter their NPI and the patient's HICN, to verify submission of their NOE. If the NOE cannot be found, CGS recommends re-submitting the NOE.
Reviewed: 09.26.16
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- Is anything going to be done when an NOE was filed timely, but contained an error?
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The requirement within CR 8877 states the NOE must be "submitted to the Medicare contractor and accepted by the Medicare contractor". An NOE that contains an error is not an "accepted" billing transaction. This is consistent with the definition of a "clean claim" found in the Medicare Claims Processing Manual (Pub. 100-04) Ch. 1, section 80.2
Reviewed: 09.26.16
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- Is there a way to indicate when we are re-entering an NOE that was backed out for a prior billing that it in fact had been already submitted and paid timely and this is simply a re-entry? Otherwise it goes thru as LATE.
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Currently, the only process to handle an NOE that was backed out to allow for a prior hospice to bill is to go through the exception process. When the prior hospice has completed their billing, the subsequent hospice can re-submit their NOE. The claims with "noncovered" dates of service due to the untimely NOE must include the modifier 'KX', so they can be stopped to request the exception documentation for review. When submitting documentation for the exception request, include documentation to show the reason the initial NOE was backed out. This can include a letter, emails, or documented phone calls with the prior hospice.
Reviewed: 09.26.16
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- When duplicate NOEs are submitted (for various reasons) and FISS RTPs one due to the duplication, does the hospice need to cancel (81D or 82D) the duplication? The hospice wants to make sure that the timely NOE will remain in effect by doing a cancellation. In other words, if a cancellation is done, it will not cancel both NOEs.
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If a duplicate NOE is inadvertently submitted, it will hit a CWF edit, reason code U5106 (NOE falls within a current hospice election) and will be returned to the provider (T B9997). It will not receive a reason code indicating it is a duplicate NOE. Therefore, there is no provider action required if a duplicate NOE was submitted.
Reviewed: 09.26.16
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- We are seeing our NOEs hit the edit/reason code of F5052. I understand that this reason code is a Medicare edit that is holding our NOE from processing. The NOE is stuck in that reason code for several weeks and not returned to the provider (RTPd). We recently called on one beneficiary NOE and were told that we had the incorrect HIC number. Is there a reason why these are not being returned to RTP timely for us to correct? And what recommendation would you give us for claims stuck with this reason code?
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To avoid the risk of having an incorrect HIC number, hospices should verify the beneficiary's eligibility information using one of the eligibility systems. The reason code F5052 indicates that the NOE is searching the various host sites at Common Working File (CWF) for the beneficiary's information. This reason code does not necessarily indicate that there is a problem. If the beneficiary's information cannot be found after searching the various host sites at CWF (for example, due to an invalid HIC number) the claim will then be RTPd. However, the process to search the CWF host sites can take several days.
Reviewed: 09.26.16
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- What if a patient has MSP and the primary insurance does not pay all charges? Does the NOE need to be timely for hospice to bill for the remaining charges?
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When a patient has another insurance that is primary to Medicare, CGS recommends billing Medicare as the secondary payer, even in cases where the provider expects to receive payment in full from the primary insurer. This protects the hospice in case the primary insurer retroactively terminates the benefits. The NOE must be submitted timely if Medicare payment is desired/expected. Note that the NOE must be submitted with Medicare as the primary payer.
Reviewed: 09.26.16
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- Black out days: We had several NOEs that were submitted within the 5 day requirement (example: submitted a day before a black out day –December 24, Christmas Eve), but were not accepted by CGS until 2 days later (December 26), which made them untimely. Please explain the rule of submission prior to black out days in order for an NOE to be considered timely.
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When an NOE is submitted into the FISS system, that is considered the date of receipt. Therefore, if your NOE was submitted on December 24, it would have been accepted by CGS on December 24 – not December 26. However, on holidays such as Christmas (December 24 and 25) and New Years Day (January 1), FISS will not cycle, meaning the NOEs will not proceed through the claim processing edits. In the case above, the NOE was submitted timely and should not have been considered untimely unless the NOE RTPd for an error. If the NOE was RTPd, and a request for an exception has been made, CGS would consider the non-cycle days which delayed the processing, and subsequent RTPing, of the claim. As a reminder, when requesting an exception, if the processing of the NOE was delayed due to dark days, the hospice should include this information in their exception request.
Reviewed: 09.26.16
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- If you submit an NOE and the receipt date is under the 5 days, and it is in an 'S' (suspended) status, could it take longer than a couple days to be returned, which would make it untimely? Do I need to keep checking the NOE until it goes to a 'P' (paid) status? Most of my NOEs take 6-9 days after I have submitted them to see the 'P' status.
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NOEs begin processing through the edits in FISS. If an error is found by FISS, the NOE is returned to the provider (RTPd) relatively quickly – usually within a day or two. However, there are additional edits that an NOE goes through at the Common Working File (CWF). This process can take several days, perhaps up to a week or more. If an error is found by the edits at CWF, the NOE will be RTPd, and the NOE will likely be untimely. CGS recommends that hospices verify the accuracy of their NOE before submitting it. In addition, hospices can monitor the status of their NOE, as often as daily, using FISS. As a reminder, an NOE does not need to be in a "P" (paid) status within 5 days to be considered timely.
Reviewed: 09.26.16
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- We've noticed that if a keying error relates to the admit date, period From date, and/or the occurrence code 27 date, the NOE is returned immediately and is able to be fixed within the 5-day timeframe. If, however, the keying error relates to the HICN, it takes over two full weeks for the NOE to show up in Return to Provider. We're fortunate enough to have a data entry person with exemplary keying accuracy, but she is human, and since every NOE must be keyed manually, there will be keying errors. They are already capable of immediately returning date entry errors so it certainly seems like their computer system should be able to identify HICN and all other keying errors immediately as well. Is there going to be edits in place to catch these keying errors where NOE's are not returned to provider in order that we are able to fix within the 5 days?
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The amount of time it takes for an NOE to be returned to the provider is dependent upon the editing within the claims processing systems; the Fiscal Intermediary Standard System (FISS) and the Common Working File (CWF).
If an error is identified through edits in FISS, these can be returned to the provider (RTPd) soon after submission. FISS edits include things such as a missing occurrence code 27 or date, an incorrectly formatted HICN, an incorrectly formatted or unrealistic date (FROM, TO or ADMIT), an invalid type of bill, or an incorrectly formatted physician NPI.
However, edits in CWF can take several days to two weeks to be identified.
CWF edits include things such as a beneficiary name/HICN mismatch, an incorrect/inconsistent occurrence code 27 date, or an overlapping hospice election.
While this editing is inherent within FISS and CWF, and cannot be changed, providers should verify the patient's eligibility information prior to submitting the NOE, and verify the accuracy of the information keyed, to reduce the risk of having an untimely NOE due to a keying error.
Reviewed: 09.26.16
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- One of the NOE errors noted on slide 10 states "referring and attending physician cannot be same". What if the referring MD and Attending MD is the same?
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If the attending and referring physician are one in the same, only the ATT PHYS field needs to be completed.
Reviewed: 09.26.16
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- A patient was referred by an oncologist, and entered as patient's attending physician with the NOE. Approximately 4 days into the admission, the patient decided she would prefer her primary care physician to act as attending physician rather than the oncologist. Does changing the attending physician necessitate the need to re-enter the NOE? Doing this would result in it being untimely.
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If the patient chose to change his/her attending physician, there is no need to cancel the NOE, and rebill it. However, if the incorrect attending physician was reported on the NOE, it would need to be canceled and rebilled with the correct physician information. Change Request 9114 (MLN Matters® MM9114), which is effective October 1, 2014, provides instructions for hospices to follow when a beneficiary wants to change their choice of attending physician.
Reviewed: 09.26.16
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- I was not aware that NOEs could be submitted electronically through a clearinghouse. I thought that all NOEs had to be hand-keyed into DDE. When did this rule change and do you know if it applies to all FIs?
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NOEs must be submitted direct data entry. They cannot be submitted via the 5010 format. However, some clearinghouses may have the ability to submit NOEs on behalf of a hospice agency.
Reviewed: 09.26.16
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Exception Requests
NOTRs
- A patient was discharged and came back on service 5 days later. Can condition code 52 (not in service range) no longer be used? In this case, the patient went to a hospital that we do not have a contract with. We need to submit an 81B. Is that going to affect my ability to finish our billing for the period? Would the occurrence code 42 and condition code 52 be reported on the 81B?
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In this case, an 81B should be submitted within 5 days of the discharge, if the final claim has not already been submitted. The NOTR requires only limited information. The 81B should not include a condition code 52 or an occurrence code 42. For more information on what data should be reported on an NOTR, refer to the Claims Filing Web page of the CGS website, under the Notice of Termination Revocation header.
Reviewed: 09.26.16
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- When will issues that result in error codes U5114 (TO date on NOTR is greater than TERM DATE of posted benefit period) and U5109 (no benefit period for NOTR date) for NOTRs be corrected?
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There is no known date for resolving this issue. This has been reported to CMS.
Reviewed: 09.26.16
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- My question is in reference to cancelling an 81B (NOTR). When CR8877 first came about, I was told in order to cancel a NOTR, you had to back out all claims within the time frame of the NOTR, and then 81D the 81B. Very time consuming… Has this process changed now since we are able to key the 81Bs in the 02, 49 option like an 81A? I cannot find anything related to this in the Medicare manual.
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When an 81B is submitted with an incorrect date, this results in an incorrect revocation date (i.e. TERM DATE) posting to the benefit period. The only way to remove the revocation indicator, and the incorrect date, is to delete the benefit period. To accomplish this, an 8XD must be submitted. Note that any claims with dates of service within that benefit period must be canceled before the 8XD can be submitted. The only thing that changed as a result of Change Request 8795
was to allow hospices to submit an 8XD using FISS Option 49 (NOE/NOA), rather than option 28 (Hospice).Reviewed: 09.26.16
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- If I have not done a NOTR within 5 days of discharge/revocation, what will happen? We have 2 patients that have been discharged in January.
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There are no system or payment consequences for submitting the NOTR untimely. However, submission of an NOTR within 5 days after discharge/revocation is a CMS requirement, and is necessary to ensure prompt updating of the beneficiary's eligibility record to ensure they have access to medical care. If a patient is readmitted to hospice, and the subsequent NOE RTPs due to an overlapping open hospice benefit period for the same agency, and the NOTR (or final claim) was not submitted timely, the exception request may not be granted.
Reviewed: 09.26.16
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- Do we submit a Notice of Termination/Revocation (NOTR) for a patient who was discharged, revoked, or transferred?
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An NOTR must be submitted within 5 days after a discharge or revocation from the Medicare hospice benefit. A hospice transfer is a continuation of a current hospice benefit period. Therefore, an NOTR should not be submitted if a patient is transferring to another hospice without a break in hospice care.
Reviewed: 09.26.16
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