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Examples of Denied/Granted RAP Exception Requests

Medicare guidelines allow for four exceptions if a Home Health Request for Anticipated Payment (RAP) is not filed timely. To request an exception, information supporting the circumstances must be entered in the REMARKS field on the claim. Refer to the Submitting a Final Claim under the Home Health Patient-Driven Groupings ModelExternal Website web page for information about requesting an exception for an untimely RAP submission.

The following provides scenarios where exception requests were denied or granted by CGS.

Example #1:

Submitted Remarks:

RAP was late due to EDI issues. Was not able to get the 999 report.

Review Outcome:

Non-medical review Additional Development Request (non-MR ADR) was generated.

The Claims department determined that the information provided in the REMARKS field did not include enough information to make a determination. A non-MR ADR was generated to obtain documentation showing when the information was received.

Suggestion: Include details that support the reason the RAP was submitted untimely and what action was taken (e.g., called EDI on MM/DD and was told about 999 report issues; our office had system issues and was not able to get the 999 report).

Example #2:

Submitted Remarks:

RAP was billed timely on 1/9/21 please reconsider.

Review Outcome:

Exception granted.

The Claims department reviewed the Fiscal Intermediary Standard System (FISS). The RAP was submitted timely but went to the Return to Provider (RTP) file with reason code U538I. Since it was corrected/rebilled within 2 business days, the exception was granted.

Example #3:

Submitted Remarks:

Late due to system issue.

Review Outcome:

Non-MR ADR was generated.

The Claims department determined that the information provided in the REMARKS field did not include enough information to make a determination. A non-MR ADR was generated to obtain documentation identifying the system issue that caused the untimely filing.

Suggestion: Explain what system issue affected the submission of the RAP. Was it a FISS issue, or an issue with your home health agency’s system, or a vendor system issue? Refer to the Claims Processing Issues LogExternal Website and reference the specific issue, when applicable.

Example #4:

Submitted Remarks:

RAP was billed timely but was cancelled due to an incorrect admission date.

Review Outcome:

Exception granted.

The Claims department reviewed the Fiscal Intermediary Standard System (FISS). Since the RAP was corrected/rebilled within 2 business days, the exception was granted.

Example #5:

Submitted Remarks:

Billing software issue.

Review Outcome:

Exception not granted.

The Claims department determined that the information provided in the REMARKS field did not include enough information to make a determination. A non-MR ADR was generated to obtain documentation about the billing software issue. The provider responded by submitting medical record documentation, which did not include additional information about the billing software issue; therefore, the exception request was not granted.

Suggestion: If you have access to FISS Direct Data Entry (DDE), RAPs may be submitted via FISS DDE when necessary. Refer to the Submitting a Request for Anticipated Payment (RAP) under the Home Health Patient-Driven Groupings ModelExternal Website for information about billing RAPs via FISS DDE.

Published: 04.05.21

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