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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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Resources for the Most Common Home Health and Hospice Medicare Questions

Listed below are the most common reasons home health and hospice providers contact the CGS Provider Contact Center – Phone number (877) 299-4500 (Option 1).

Please review the list of resources under each topic before contacting the CGS Provider Contact Center for these reasons.

Address/Phone/Fax

  • Home Health & Hospice Contact Information – Interactive Voice Response (IVR) telephone number; IVR User Guide; home health and hospice Provider Contact Center (PCC) telephone number (customer service and Electronic Data Interchange (EDI)); PCC Holiday/Training Schedule; congressional inquiries fax number; mailing addresses to send correspondence, claims, appeals, enrollment information, overpayments, cost reports, and credit balance reports.
  • Other Home Health and Hospice Provider Contact InformationExternal Website (CMS Cost Report Overview webpage) – If you have the other agency's Provider Transaction Access Number (PTAN) or name, use this resource to obtain the, telephone number, and address of the home health agency (HHA) or hospice for assistance in resolving overlapping claim issues.
    • To access home health information, click on "Home Health Agency" and scroll down and click on the "HHA Reports Zip File" link to open a ZIP file, and then select the "HHH_Provider_ID-Info" file to download a spreadsheet containing the contact information for HHAs.
    • To access hospice information, click on "Hospice" and scroll down and click the "Hospice Reports" link, and then select the "hospc_prvdr_id info" file to download a spreadsheet containing the contact information for hospices.
    • National Plan & Provider Enumeration System (NPPES)External Website – Use this resource to obtain contact information to resolve overlapping claim issues.
  • Medicare Advantage (MA) Plan DirectoryExternal Website – Find the contact information for any Medicare Advantage plan in which your beneficiary is enrolled. The MA plan contract number can be found in the "PLAN-ID" field on ELGH page 5 or the PLAN-TYPE field on ELGA page 1. If using the eligibility function in myCGS, the MA Plan's contact information is displayed on the "Plan Coverage" tab. Refer to Chapter 4: Eligibility Tab of the myCGS User Guide for additional information.
  • Helpful Links – Websites that provide wide variety of resources.

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Beneficiary Demographic Information

  • See the "Checking Beneficiary Eligibility " Web page for the options available to determine a beneficiary's demographic information, and instructions for using these resources.

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Calculation or Explanation of Payment

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Claims in a Suspended Status/Location (S/LOC)

  • Suspended claims can be identified in the Fiscal Intermediary Standard System (FISS) by the status code "S" (e.g., S B0100).
  • Generally, providers do not need to take action for claims in a suspended S/LOC. All claims will temporarily suspend in different S/LOCs as they process through FISS.

Below are just some of the common suspended S/LOC codes and what they mean. Refer to the "Fiscal Intermediary Standard System (FISS) Common Locations " Web page for more.

S/LOC Definition Provider Action Needed?
S B0100 System processing No
S B6001 Claim needs additional information from provider (ADR). Yes, a medical review additional development request (ADR) must be received by CGS within 45 calendar days.
S B90XX (XX=denotes a variety of location codes) System is comparing claim data to beneficiary eligibility information posted at the Common Working File (CWF). No
S M0XXX (XXX=denotes a variety of location codes) Suspended claims/adjustments requiring manual intervention by CGS staff. No. Suspended claims/adjustments that require CGS staff intervention may be suspended for about 30 days. Claims with Medicare Secondary Payer (MSP) information may be suspended for more than 60 days. Providers may call the Provider Contact Center if their claim has been in the same "S MXXXX" S/LOC for longer than 30 days, or 60 days for MSP claims.
S MRADJ A Medicare Secondary Payer (MSP) adjustment has been received; claim suspended while awaiting completion. No
S M50MR Medical Review (claim moved to this location once medical documentation has been received.) Please note: the review process may take up to 30 days to complete or 60 days for demand denials. Do not call regarding this status/location unless your claim has been there for more than 60 days. No

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Claims Processing Issues

When calling to report or to receive an update about claims processing issues with the Fiscal Intermediary Standard System (FISS), check the Claims Processing Issues Log Web page for the latest update, prior to calling the CGS Provider Contact Center.

Correcting Invalid Information Posted to the Common Working File (CWF)

Please be aware that CGS is unable to update invalid information posted to the beneficiary's eligibility file including Medicare Secondary Payer (MSP) records, invalid dates of death, and Medicare Advantage (MA) plan enrollment/termination dates.

  • To update MSP records, contact the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 (8:00 a.m. – 8:00 p.m. Eastern Time) or by fax at 1-405-869-3307 (address the fax to Medicare- MSP General Correspondence). For more information about the BCRC, review Medicare Learning Network (MLN) Matters® article, SE1416External PDF, "Updating Beneficiary Information with the Benefits Coordination & Recovery Center (formerly known as the Coordination of Benefits Contractor)".
  • To update dates of death, or the beneficiary's name, address, or Medicare entitlement dates, contact the Social Security Administration (SSA) at 1-800-772-1213.
  • To update Medicare Advantage (MA) Plan records, determine the MA plan identification code using the "PLAN-ID" field on ELGH page 5 or the PLAN-TYPE field on ELGA page 1. Use the MA Plan DirectoryExternal Website to determine the contact information for the MA plan posted for the beneficiary. If using the eligibility function in myCGS, the MA Plan's contact information is displayed on the "Plan Coverage" tab. Refer to Chapter 4: Eligibility Tab of the myCGS User Guide for additional information. Contact the MA plan listed to update the beneficiary's eligibility record.
  • To correct hospice benefit period information, access the Submitting a Hospice Notice of Cancelation TOB 8XDPDF for additional information.
  • To correct home health episodes, access the information on the Correcting Home Health Episode Information Posted to the Common Working File (CWF) Web page.

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Coverage Issues

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Electronic Data Interchange (EDI)

Please be aware that the CGS Provider Contact Center home health and hospice Customer Service Representatives (CSRs) are unable to assist you with EDI questions related to CMS freeware, billing software, connectivity issues, or resetting your passwords for the Fiscal Intermediary Standard System (FISS) or myCGS.

  • For assistance with security issues with your access to ELGA, ELGH, FISS, or if you need to have your password reset, please email the CGS Security Administration Team at CGS.Medicare.OPID@cgsadmin.com. Be sure to include the user ID that is experiencing problems and the first and last name of the user to which that ID is assigned in your email request. You can also receive assistance with FISS, ELGA, ELGH security issues or password resets by calling 615-660-5444.
  • For all GPNet access and password issues, or password/access issues with myCGS, please continue to call the J15 EDI Helpdesk for assistance at1-877-299-4500 (select Option 2).
  • Refer to the EDI Job Aides for resources on a variety of EDI situations.

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Explanation of Reason Code

After reading through the reason code narrative in FISS, you may be able to access additional information for resolving the billing error from the Top Claim Submission Errors and How to Resolve Webpage. For instructions on reviewing reason code narratives for claims in the Return to Provider (RTP) file, access the Claims Correction (Chapter 5)PDF of the FISS Guide.

Filing/Billing Instructions

Types of billing instructions most requested:

Home Health

Hospice

Medicare Secondary Payer (MSP)

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Missing/Invalid Codes

Most common types of claims that have missing or invalid codes

Adjustments

Home Health

Hospice

Medicare Secondary Payer (MSP)

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Overlapping Benefit Periods, Claims, Episodes, Services

Home Health and Hospice

  • See the "Checking Beneficiary Eligibility " Web page for the options available to determine any overlapping Medicare services that the beneficiary is receiving that may impact your billing. Instructions for using these resources are also available on this web page.
  • Other Provider Contact InformationExternal Website (CMS Cost Report Overview) – If you have the other agency's Provider Transaction Access Number (PTAN), or name, use this resource to obtain the telephone number, and address of the home health agency (HHA) and hospice for assistance in resolving overlapping claim issues.
    • To access home health information, click on "Home Health Agency" and scroll down and click on the "HHA Reports Zip File" link, to open a ZIP file, and then select the "HHH_Provider_ID-Info" file to download a spreadsheet containing the contact information for HHAs.
    • To access hospice information, click on "Hospice" and scroll down and click the "Hospice Reports" link, and then select the "hospc_prvdr_id info" file to download a spreadsheet containing the contact information for hospices.
    • National Plan & Provider Enumeration System (NPPES)External Website – Use this resource to obtain contact information to resolve overlapping claim issues. You will need to click on the link to "Search for an Organizational Provider" to determine the billing agency's contact information.

Home Health

Additional references for overlapping services due to home health beneficiary-elected transfer, or discharge/re-admission during a 60-day episode of care:

If one of the line item dates of service (LIDOS) on your home health claim is overlapping an inpatient stay, access the information about Reason Code C7080 found on the Top Claim Submission Errors (Reason Codes) and How to Resolve Web page. CGS encourages you to use the first Medicare billable visit in the episode as the date of service submitted when billing non-routine or surgical dressing/wound care supplies to avoid errors for overlapping inpatient stays. In addition, please review the information posted to the impact of an Inpatient Admission During an HH PPS Episode Web page.

If your home health claim was adjusted or rejected due to the dates of service overlapping a Medicare Advantage (MA) plan enrollment period, refer to the information about Reason Code U5233 and 7CS21 found on the Top Claim Submission Errors (Reason Codes) and How to Resolve Web page.

If your home health episode overlaps a hospice benefit period and your services are unrelated to the terminal diagnosis, please review the information about Reason Code C7010 found on the Top Claim Submission Errors (Reason Codes) and How to Resolve Web page.

Hospice

Additional references for hospice beneficiary discharge/revocation, or transfer during a benefit period:

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Resolving Rejected Claims

Medicare claims submitted to CGS most often reject due to:

  • Duplicates: a second Medicare claim with the same dates of service for the same beneficiary is submitted by a home health or hospice agency.
  • Eligibility: the claim information submitted by the home health and hospice agency does not match the information posted to the beneficiary's eligibility record at the Common Working File (CWF). For example, a beneficiary has an open Medicare Secondary Payer (MSP) record and the dates of service submitted on the Medicare claim are after the effective date of the record.
    • CGS encourages providers to check a beneficiary's eligibility prior to admission and billing each home health episode or hospice Notice of Election (NOE) or claim to Medicare. For information on accessing, reviewing and understanding the eligibility information available to Medicare providers, see the "Checking Beneficiary Eligibility " Web page.

Depending upon the reason why a claim is rejected, a home health or hospice provider may need to send in a new claim (resubmit), electronically adjust, or send a paper claim adjustment to resolve the original billing error.

Home Health and Hospice Providers

Home Health Providers Only

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Updated: 12.21.20

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