Ask-the-Contractor (ACT) Questions and Answers
February 18, 2015, "CR 8877: Updates from CGS on Timely Filing of NOEs and Exception Requests" ACT
To access the handouts from this event, click here.
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General
- What should a provider do when there is a previous open benefit period, and the patient has revoked/been discharged? The prior claims are in ADR, and the discharge date is beyond the posted benefit period, so the NOTR will not process. The patient is now back on service, and we need to bill a new NOE.
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The hospice should still submit the NOTR and the NOE timely. You are correct that the NOTR will not process if the discharge date is beyond the posted benefit period. The new NOE will process, since the Admit Date is beyond the posted benefit period. In this case, when the ADRd claims are released, you will need to cancel your NOE to allow them to process. The NOE should be resubmitted as soon as possible after the claims are processed. Screenprints can be submitted, along with an explanation of why the NOE was canceled and resubmitted, in support of an exception request.
Reviewed: 09.26.16
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- Another MAC only requires Remarks for exception requests when the NOE hit an open benefit period. Is that something CGS is aware of or would consider doing?
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We are aware that one of the MACs is allowing remarks in these cases. However, based on the Change Request, CGS has made the decision to request documentation in these cases.
Reviewed: 09.26.16
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- When a patient revokes, we submit an 81B timely. Then the patient comes back on service a week later, and we submit a new NOE. Sometimes, the NOE will process, and other times it does not. Does the system not see that the patient revoked and came back on?
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If the 81B has processed by the time the new NOE was submitted, the NOE can process because the prior benefit period was termed. However, if the 81B has not yet completed processing to terminate the prior benefit period, the new NOE cannot process, and will hit reason code U5106. In these cases, the hospice can submit an exception request for the untimely NOE. Note that the 81B must be submitted timely in order for the untimely NOE to be considered beyond the hospice's control.
Reviewed: 09.26.16
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- Transfers are still not under this 5 day guideline. The other hospice has not completed their billing and I was told by your help desk that if I enter the 81C this will not allow the previous hospice to complete their billing. I was told to check each day until all the billing has been completed by the previous hospice. Is this correct?
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Change Request 8877 does not apply to hospice transfers. Due to sequential billing, the transferring hospice and the receiving hospice should coordinate their billing activities. The transferring hospice will need to submit their final claim before the receiving hospice can submit their notice of transfer (8XC) and their first claim.
Reviewed: 09.26.16
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- When Medicare has their grey and dark days, do these days count when submitting NOE's/NOTR's?
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CGS does consider grey and dark days when reviewing an exception request. If the grey/dark day affected the processing of the NOE, the provider should note this in their exception request. CGS would not penalize a provider for those days.
Reviewed: 09.26.16
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- I submitted an 81C (Change of Hospice) in FISS and it was returned (T B9997) because the prior hospice is still billing, and their transfer claim has not yet processed. Do I have to periodically keep checking the CWF to see where the other provider is in the billing process? Are the guidelines the same for an 81C as they are for an NOE?
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Hospice transfers and 8XCs are not subject to the 5-day billing requirement in Change Request 8877.
Reviewed: 09.26.16
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- Is there any discussion of the removal of sequential billing so we don't have to back out our NOE's for prior hospice stays not yet billed?
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CGS is not aware of any discussion about removing the hospice sequential billing requirement.
Reviewed: 09.26.16
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- Is there any discussion of the possibility of making the 5 days to file timely business days rather than calendar days? Weeks with Monday or Friday legal holidays are very difficult to be in compliance since billing staff does not work weekends or holidays.
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CGS is not aware of any discussion regarding expansion of, or revisions to, the 5 day timely filing requirement for NOEs.
Reviewed: 09.26.16
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- When a patient transfers, the NOE continues with them for the current orders. Does the transferring hospice do anything different with a transfer status? The first hospice services stops at time of transfer. The receiving hospice is then responsible for care.
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Hospice transfers are not affected by Change Request 8877. For more information on billing a hospice transfer claim, refer to the "Transferring Beneficiary From/To Another Hospice Agency" Web page.
Reviewed: 09.26.16
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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
- Can you clarify if an exception will be granted if a patient had a previous hospice and prior hospice did not bill timely. Is this true of all MACs?
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If the prior hospice (hospice A) did not bill their NOTR or final claim to terminate prior benefit period, and the subsequent hospice (hospice B) could not get their NOE processed because of that, CGS would grant an exception. However, if the discharge and readmit was with the same hospice agency, and the hospice didn't submit an NOTR timely, an exception for an untimely NOE would not be granted. MACs have met and discussed this CR and exception circumstances, and while the MACs are following similar guidelines for exceptions, hospices should consult their own MAC for guidance.
An exception request determination is based on the documentation supplied by the requesting hospice. Therefore, Hospice B should be prepared to show documentation that they submitted their NOE timely, and the open hospice benefit period at CWF that prevented the NOE from processing.
Reviewed: 09.26.16
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- On discharge and readmit patients to the same provider, we are unable to key the NOTR if the next benefit period is not created in the CWF. Example, a patient has 2 months of service held from billing because the physician has not signed the IPOC or COTI, during the end of the second month the patient discharges and goes to a non contract hospital and then re-admits to our hospice 3 days later. We will be unable to enter that NOTR for the first episode of care as the Benefit period is still showing the initial period from admission with no billed days. Will an exception be granted for this scenario?
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An NOTR should be submitted within 5 days after a patient is discharged/revokes, unless a final claim has already been submitted. The fact that the NOTR is submitted timely is considered to have met the requirement in CR 8877, even if the NOTR cannot process because of a termination date beyond the posted hospice benefit period. CGS will consider a provider's compliance with the NOTR timely filing requirement when reviewing the documentation submitted in response to an exception request.
Reviewed: 09.26.16
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- We keyed the wrong admission date on the initial NOE. When we realized the error, a new NOE was keyed with the correct admission day – this new NOE was submitted timely - within 5 days of the 'correct' admission date. The incorrect NOE paid, and the second 'correct' NOE was RTPd because it overlapped the incorrect, paid NOE? Is this an exception that would be granted?
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The circumstances which caused the 'correct' NOE to RTP was due to the initial NOE being submitted with an incorrect date. This situation is not considered to be "beyond the control of the hospice". Therefore, an exception request would likely not be granted in this case.
Reviewed: 09.26.16
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- If I have several months of claims that are going to be affected by a late NOE, due to having to wait for another hospices' sequential billing, can they be submitted for review all at once or do they have to be submitted individually? I will have Oct, Nov, Dec, Jan and Feb claims that are behind due to another hospices late billing. Do I need to submit Oct with the KX modifier and comments and let it go into non-medical ADR, wait for it to be reviewed and processed before I can do the same thing for Nov? Or can I submit them one after another, so they are sequential, and then let them all go into non-med ADR status and send the documentation for all of them at one time? Can the screen shots from DDE act as some of my documentation? How long will the ADR review process take in these instances?
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In cases where an untimely NOE results in noncovered days that span more than one month, it is possible to have more than one affected claim in FISS at a time. However, claims should not be held just so they can be submitted together. Hospices still need to adhere to timely filing and sequential billing requirements. The modifier 'KX' should be applied to any claim where an exception is being requested. When we review documentation for an exception request, if we determine that subsequent claims are also pending review, we will apply the decision to all impacted claims. However, we would encourage providers to respond to each non-MR ADR request individually; that is, using a separate cover sheet, and copies of the documentation for each claim/request. Screenshots of the FISS screens can be used as a portion of your documentation; however, additional documentation may also be necessary.
Reviewed: 09.26.16
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- If a claim is sitting in status/location S M87DR how many days until a determination is granted?
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CGS reviews exception request documentation in the order it is received, and as soon as possible. Please allow for 30-45 days for the documentation to be reviewed.
Reviewed: 09.26.16
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- If you have a claim 11/07/14- 11/30/14 that you are requesting an exception and it is sitting in status/location S M87DR can you go ahead and submit the next months claim?
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Yes, if a prior claim is pending review by CGS for an exception request, it is permissible to submit the next month's claim. If the subsequent claim is pending when CGS renders the exception request determination, and the decision impacts the subsequent claim's dates of service, the decision can be applied to both claims.
Reviewed: 09.26.16
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- We have had several patients that I have entered the NOE within the 5 day limit. The NOE is processing but in the meantime, the patient revokes, and then is readmitted to our hospice a day or two later. The first NOE has not finished processing, but I put the NOE for the second admission in so that I will be within the 5 day limit. The second NOE processes right away, and my first NOE goes into a T status because of the open episode. I then have to put an 81D in to cancel this second 81A and by the time I am finally able to release the first 81A I am well over the 5 day limit. Will this be granted an exception?
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If you submit your second NOE a few days after the first NOE, the first NOE should process before the second, unless the first NOE is returned to the provider (RTPd). However, if the second NOE does happen to process before the first, you will have to cancel the second NOE to allow the first NOE to process. In this case, if the provider submits documentation showing the second NOE was canceled to allow the prior NOE to process, and documentation supports this was beyond the hospices control, an exception would be granted. However, if documentation indicates that the initial NOE was billed incorrectly (RTPd), or otherwise within the hospice's control, an exception may not be granted. CGS reviews all exception request documentation that is submitted, and each situation is considered on a case-by-case basis.
Reviewed: 09.26.16
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- You stated that if a patient was discharged and readmitted to the same hospice, and the NOTR (8XB) was not filed timely, CGS would deny the exception request if the NOE hit an overlap edit (U5105 or U5106). My understanding was that there was no financial penalty for not filing an NOTR timely. Would that not be a financial penalty? Also if you are billing that claim period and it is the same days as the 81B do you still need to enter the 81B?
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There is no financial penalty for late filing of the NOTR, itself. However, when requesting an exception for an untimely NOE, CR 8877 states that to qualify for an exception, the circumstance must be "beyond the control of the hospice". When an NOTR was not filed timely by the hospice, the prior benefit period cannot be terminated, which results in the NOE overlapping the prior benefit period. Since this situation is within the control of the hospice agency, an exception cannot be granted, and the hospice would be liable for those noncovered days.
Reviewed: 09.26.16
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- If we have a 77 occurrence code that spans from 10/27/15 - 11/06/15, and we have asked for a KX modifier on the October claim that is granted will we still need to ask for a KX modifier on the November claim and include all of the same information?
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When an untimely NOE spans more than one month, the subsequent month's claim should also reflect the noncovered days. If you are requesting an exception, the modifier 'KX' must be reported on all claims that have noncovered days due to the untimely NOE. In this example, both the October and November claims must include an occurrence span code 77 indicating the noncovered days on the claim (based on the claim's FROM and TO dates), and the modifier 'KX' to request the exception. Documentation should be sent separately, for both claims. If the November claim is already in the system when the October exception request is reviewed, CGS will process the November claim based on the exception request determination that was made on the October claim.
Reviewed: 09.26.16
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- I mistakenly keyed an NOE as a 01A type of bill. I was unable to find it in my RTP file since we check the RTP file for 81As. Shouldn't this be a valid exception?
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Keying errors are not a valid reason for an exception. To avoid this issue, use FISS Option 12 to monitor the status of the NOE. Enter only your NPI and the beneficiary's HICN. You may also use the Hospice Claims Correction option (Option 29), and remove the value auto-plugged in the TOB field. In addition, if the provider is aware of a keying error on a submitted NOE, the provider may choose to resubmit the NOE, rather than waiting for the incorrect NOE to RTP.
Reviewed: 09.26.16
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- We accepted patients from a prior hospice that lost their Medicare certification. They have not completed their billing, and our NOEs RTPd with U5106. We have contacted them several times. What documentation do we need to submit with our exception request?
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If the prior hospice completes their billing, F9 the NOEs as soon as their billing is complete. The exception request should include documentation showing the prior open hospice benefit period and your attempts to contact the prior hospice, including call dates and who you spoke to.
If the prior hospice does not complete their billing, contact the CGS Provider Contact Center for assistance 877-299-4500 (Option 1).
Reviewed: 09.26.16
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- What is the proper process for requesting an ADR after a claim with a KX and a span date is denied so that we can submit proof of timeliness? Can the request be faxed rather than mailed? Are the submission rules the same for CGS and Palmetto?
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To request an exception, the modifier 'KX' must be reported on the claim. This will generate a non-Medical Review additional development request (non-MR ADR), and the claim will move to stat/location S B6001 with reason code 39701. Documentation to support your exception request can either be faxed (preferred), mailed or sent via esMD. The fax number and mailing address are below.
FAX: 1.615.660.5982
Mail: CGS J15 MAC
J15-HHH Claims
PO Box 20019
Nashville, TN 37202For additional information about the exception request process, refer to the "Requesting an Exception for an Untimely NOE" Web page on the CGS website.
Reviewed: 09.26.16
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- We faxed our exception request documentation. Our fax machine indicated successful submission. We are checking FISS for the S M status. What is the appropriate time to wait for the S M87DR status before re-faxing the documentation to ensure timely filing?
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Typically, claims are moved to S M87DR within 2-3 business days of receipt of the faxed documentation. Providers should ensure they are using to correct fax number, 1.615.660.5982, to send their exception request documentation. If documentation is sent to another CGS fax number, this may delay movement of the claim.
Reviewed: 09.26.16
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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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Claims for Untimely NOEs
- Initially, we understood that it was optional to include noncovered charges (visits and drugs) when requesting an exception (report a modifier KX). Are we required to report visit and drug charges as noncovered due to an untimely NOE?
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Yes, hospices should include the visits and drugs within the noncovered period on their claim, and these should be reported as noncovered charges. This information should be reported for CMS data collection purposes. If an exception request is granted, the claim should reflect all visits and drugs provided during the billing period.
Reviewed: 09.26.16
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- Is there a way to correct the units, rather that deleting and re-keying, when the claim hits reason code 34923 (slides 19 and 20 of the handout)?
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No, the revenue code line(s) for the noncovered dates must be deleted and re-keyed.
Reviewed: 09.26.16
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- On subsequent claims where the late NOE spans into the next month, if you do not use the 77 code and span on the claim will the claim pay with no issues? If the claim does pay, will CGS find these claims and process an automatic cancel and repay for the only covered days in the month or is it up to the provider to adjust these claims and add the 77 code and span date so the non covered days are not paid? We have several claims where we billed the subsequent month with no 77 code expecting the claim to reject for late NOE as the initial month did, but it actually goes through and pays with no problems.
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CR 8877 states that when an NOE is untimely, all days from the date of admission to the day before the NOE is received, must be reported as noncovered. Therefore, when an untimely NOE spans into the next month, an occurrence span code (OSC) 77 should be reported on the subsequent month's claim. CGS has implemented edits to prevent subsequent claims, due to an untimely NOE, from processing when an OSC 77 is not reported. If a subsequent claim is processed and paid inadvertently, the hospice should do an adjustment (8X7) to report the OSC 77 and show the affected days as noncovered. CGS also has the authority to adjust any claims that were paid inappropriately.
Reviewed: 09.26.16
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- When ALL dates on a claim are noncovered due to untimely NOE (admit to death), and the claim rejects (R B9997) and I'm not requesting an exception, is the claim considered "complete" when it reaches the R status? Do I need to do anything else to have the claim report to Medicare?
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Yes, if all days on the claim are noncovered due to an untimely NOE, the claim will process and appear in a rejected status/location (R B9997). This location is considered a finalized location, and no additional action is required by the provider.
Reviewed: 09.26.16
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- I had a claim from October 2014, in which the patient admitted and discharged 2 times within the month, days close together, causing me an NOE timely issue. I was prepared for that, but when I sent out my final claim, I had forgotten about it and sent that claim without marking the days that should have been non-covered, also prepared for the claim to go into ADR status, which it did. I did send my ADR information in as required on 1/14/15 by fax, but here is what I am concerned about. Since I did not submit the final properly (with the non-covered lines) and it went into ADR status immediately, will this cause the ADR to deny? All the appropriate paperwork was sent in and I am confident that this should be a granted exception, other than the initial final having incorrect line items, and sent as a routine looking final.
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A claim must include a 'KX' modifier to be ADRd for the exception process. If an NOE was not submitted timely, and the claim did not include the occurrence span code 77 and/or noncovered days, the claim would be RTPd with reason code U5194. If an exception is granted, the occurrence span code 77 is removed, and the claim is released to process. If however, the exception request is not granted, CGS will add the occurrence span code 77 and show the days and services, from admission to the day before the NOE was received, as noncovered.
Reviewed: 09.26.16
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- I have electronically submitted claims that have gone into RTP due to the fact the KX modifier was not on the original claim. Will I be able to add the KX and F9 the claims to generate the non-MRADR exception process?
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If the 'KX' modifier was not reported on the claim, it would not RTP, unless other information (such as the occurrence span code 77 and/or date) were also missing. If a claim is submitted without the 'KX' modifier and processes, and you wish to request an exception, an adjustment claim (type of bill 817 or 827) can be submitted to report the 'KX' modifier.
Reviewed: 09.26.16
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