Examples of Denied/Granted Exception Requests
Medicare guidelines allow for four exceptions if a hospice Notice of Election (NOE) is not filed timely. The following provides scenarios where exception requests were denied or granted by CGS. Refer to the "Requesting an Exception for an Untimely NOE" Web page for additional information.
Example #1: |
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Case Facts: |
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Review Outcome: |
Exception request not granted. |
Example #2: |
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Case Facts: |
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Review Outcome: |
Exception not granted due to provider billing error (invalid TOB). Exception granted for claims received on or after November 16, 2016, and if the hospice took appropriate action within 2 business days, after claim went to RTP, to make the correction. |
Note from CGS: |
CGS recommends checking status of NOEs using FISS Option 12, and entering NPI and Medicare ID OR use Claims Correction Option 29 (Hospice) and remove TOB.
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Example #3: |
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Case Facts: |
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Review Outcome: |
Exception not granted due to billing error (incorrect/invalid OC 27 date). Exception granted for claims received on or after November 16, 2016, and if the hospice took appropriate action within 2 business days, after claim went to RTP, to make the correction. |
Example #4: |
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Case Facts: |
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Review Outcome: |
Exception not granted due to provider did not submit NOE timely |
Note from CGS: |
If hospice had submitted NOE timely, and NOE hit U5106 (overlap of open hospice benefit period), this exception would have been granted, as the circumstance would have been beyond the hospice’s control. |
Example #5: |
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Case Facts: |
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Review Outcome: |
Exception not granted due to provider billing error. Exception granted for claims received on or after November 16, 2016, and if the hospice took appropriate action within 2 business days to submit the 81D. |
Note from CGS: |
The condition code D0 and occurrence code 56 can be used to correct an NOE dates. Refer to the Claim Page 01 – Correcting a Notice of Election (NOE) web page for additional information. |
Example #6: |
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Case Facts: |
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Review Outcome: |
Exception granted due to prior open benefit period and timely submission of NOE. This circumstance was beyond the hospice’s control. |
Note from CGS: |
For discharge/readmit to same hospice, timely filing of final claim/NOTR will also be considered. |
Example #7: |
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Case Facts: |
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Review Outcome: |
Exception granted due to documentation and prompt submission of NOE once file updated. This circumstance was beyond the hospice’s control. |
Note from CGS: |
If the beneficiary file contains incorrect information, providing a screenprint of FISS Inquiry Option 10 and ELGH will help justify the exception request. |
Example #8: |
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Case Facts: |
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Review Outcome: |
Exception granted due to circumstances beyond Hospice B’s control. |
Posted: 12.17.18