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Medicare Advantage (MA) Plans — Claim Filing Tips When A Beneficiary Receiving Home Health Services Enrolls / Disenrolls

When a beneficiary is enrolled in an MA plan, the home health services provided during their enrollment period must be submitted and processed by the MA plan, not the Medicare Administrative Contractor (MAC) like CGS.

Review the following tips to help reduce billing issues that often occur when the beneficiary is enrolled in an MA plan.

  • Upon admission for Medicare covered services, review all insurance (including Medicare Part D) cards the beneficiary has and verify the information on the card is valid.
  • Upon admission and prior to billing CGS, verify whether an MA plan will impact your home health episode dates of service by checking the beneficiary's Medicare eligibility information. See the CGS Checking Beneficiary Eligibility Web page for more information about the systems available to providers to check Medicare beneficiary eligibility information.
  • Review the Bill Code field on the myCGS "Plan Coverage" tab or the OPT field on ELGA page 1 and/or ELGH page 5 to determine where the claim needs to be sent for payment.
    • If the Bill Code or OPT code is a 'C', the MA plan is responsible for processing the claim.
    • NOTE: It is never appropriate to submit billing transactions (Requests for Anticipated Payment (RAPs), final claims, adjustments, etc.) to traditional Medicare contractors (i.e. CGS) when an MA plan displaying code "C" impacts your dates of service and there is no hospice election for the beneficiary for the same dates of service.
    • If the Bill Code or OPT code is a '1', services may be submitted to CGS for processing.
NOTE: Effective January 5, 2015, home health requests for anticipated payment (RAPs) with a "From" date that falls within a Medicare Advantage plan enrollment period will be processed (P B9997) with no payment. A non-payment code 'Z' will display in the NPC field on the Claim Summary Inquiry screen (MAP1741). For additional information, refer to the MLN Matters® article, MM8710External Website.

How MA Plan Enrollment Impacts the Home Health Episodes/Periods of Care and Hospice Elections

Review the following for assistance in understanding how MA plans impact home health episodes/periods of care, as well as how a hospice election impacts a beneficiary's enrollment in a MA plan while they are receiving home health services.

Additional Information

For more information about MA plans and HH PPS, see the Medicare Claims Processing Manual, (CMS Pub. 100-04, Chapter 10, § 10.1.5.2 & 80External PDF).

Updated: 12.23.19

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