Corporate

Hospice Sequential Billing

A Notice of Election (NOE) must be submitted to Medicare, and must be processed prior to submitting your first hospice claim. To be considered processed, your NOE must appear in status/location P B9997. Use FISS Option 12 (Claim Inquiry) to verify that your NOE is in status/location P B9997 before billing your first claim.

Claims must also be submitted sequentially. When sequential billing requirements are not followed, the claim will move to your return to provider (RTP) file (status/location T B9997).

To meet the sequential billing requirements, claims must be:

  1. Submitted sequentially – This means that January's claim, for example, must be submitted before February's claim can be submitted. The Fiscal Intermediary Standard System (FISS) will search claim history for a prior claim.

    • If a prior claim is not found in a finalized or suspended status/location (P B9997, R B9997, D B9997 or S XXXXX), the incoming claim will be sent to the RTP file.
    • If the prior claim is in the RTP file (T B9997) and needs correcting, the incoming claim will be sent to the RTP file with reason code 37402. FISS does not search the RTP file (T B9997) for prior claims.

      Note: You must correct the claims out of RTP sequentially. For example if the January claim is in RTP because of an invalid HCPC code, and the February claim was submitted, the February claim would go to RTP because no prior claim was found. You must first correct the January claim. Once the January claim is corrected and moves to a suspended status/location, the February claim can be F9ed out of RTP.

    • If the prior claim is in a suspended status/location (S XXXXX) the incoming claim will move to a suspended status/location until the prior claim has been finalized. Once the prior claim has finalized (P B9997, R B9997, or D B9997), the incoming claim will continue processing.

    At any time while a claim is processing, it may move to the RTP file. CGS suggests monitoring your claims on a regular basis. If a prior claim is in RTP, make any necessary corrections to the claim to allow continued processing. To determine the status/location of your claim, refer to the Checking Claim Status Web page; AND
  2. Submitted consecutively – This means that there cannot be any skip in dates between the prior claim's "TO" date, and the next month's claim's "FROM" date; AND
  3. Submitted monthly – Hospices are required to bill claims monthly (see Medicare Claims Processing Manual (CMS Pub. 100-04), Ch. 11, §90External PDF). This means providers should bill only one claim per month, for each patient. The "To" date on the claim must be the last calendar day of the month, unless the patient died, was discharged or revoked hospice during the month.

    In addition, hospice claims must conform to a calendar month (Jan 1 – Jan 31). Claims that span two months (ex. Jan 1-Feb 1) will be sent to the RTP file for you to correct.

We recommend that you follow the steps below to ensure compliance and to avoid sequential billing errors:

STEP 1: Submit the NOE to Medicare.

STEP 2: Use the FISS Option 12 (Claim Inquiry) to verify when the NOE has processed (status/location P B9997). Note: If a claim is submitted before the NOE has processed, your claim will be sent to the RTP file (status/location T B9997).

STEP 3: After the NOE has processed (P B9997), submit the first claim. Ensure the "From" date and the "Admit date" on your claim matches the "From" date and "Admit date" on the NOE. If your patient status code indicates the patient is still a patient (PT ST = 30), the claim's "To" date must be the last calendar day of the month.

STEP 4: Use Option 12 (Claim Inquiry) to verify that your first claim appears in FISS, in a finalized or suspended status/location (P B9997, R B9997, D B9997 or S XXXXX). Claims in RTP (T B9997) are not 'received' claims. Refer to the Checking Claim Status Web page for additional information about Option 12.

STEP 5: After you verify that the claim is in a finalized or suspended status/location, submit the next month's claim. Ensure the "From" date on the claim you are submitting is one day after the "To" date on the previous claim. Ensure the "To" date on the claim you are submitting is the last calendar day of the month (unless the beneficiary died, was discharged, or revoked hospice).

STEP 6: Repeat Steps 4 and 5 for subsequent claims.

Sequential Billing and Transfers

Due to sequential billing requirements, hospices that are transferring a beneficiary to another hospice must submit their last claim (type of bill 8X1 or 8X4), indicating the transfer (patient status code 50 or 51), prior to the receiving hospice submitting their Notice of Transfer (type of bill 8XC). Receiving hospices who submit their claim before the transferring hospice submits their last claim may have their claims canceled. For more information about hospice transfers, refer to the Transferring Beneficiary From/To Another Hospice Agency Web page.

Updated: 09.18.17


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