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July 29, 2015

Hospice Exception Request and Non-Medical Review Additional Development Request Reminders

The home health and hospice Provider Contact Center (PCC) are experiencing an increase in telephone calls related to exception requests and non-medical review (MR) additional development requests (ADRs).  Please review the following reminders and share with your appropriate staff.

  • Hospice exception request documentation is being faxed to the incorrect fax number.  When the ‘KX’ modifier is reported, a non-MR ADR will be generated.  The exception request claim will move to the status/location S B6001 with the reason code 39701 and 78877.  Take the following steps to review the non-MR ADR and to locate how your documentation can be submitted.
    1. Access FISS Page 07 to view the DUE DATE.
    2. Press F8 to view the 78877 reason code narrative
    3. Press F6 to view the second page of the 78877 narrative.  This provides the mailing, and fax information.  Once the documentation is received by CGS, the claim is moved to status/location S M87DR.  If the documentation is sent to the incorrect fax number, there will be a delay in moving the claim to S M87DR.

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Refer to the “Requesting an Exception for an Untimely NOE” Web page for more detailed instructions.

  • Provider’s dissatisfaction with hospice exception request determinations.  Exception requests determinations are made by the CGS Claims department.  The Customer Service Representatives (CSRs) in Provider Contact Center do not make those determinations.  If your exception request is denied, the noncovered days can be appealed by following the Medicare Appeals Process.

 

As a reminder, the Medicare guidelines provided in Change Request 8877, included the following four exceptional circumstances for submitting an untimely hospice Notice of Election (NOE). 

    1. Fires, flood, earthquakes, or other unusual events that inflict extensive damage to hospice’s ability to operate;
    2. An event that produces a data filing problem due to CMS or contractor system issues, beyond the control of the hospice;
    3. Newly Medicare-certified hospice that is notified of certification after Medicare certification date, or awaiting user ID from Medicare contractor; or
    4. Other circumstances determined by the Medicare contractor (i.e. CGS) or CMS to be beyond hospice’s control.

For additional guidance to determine if you should submit an exception request, please refer to the “Examples of Denied/Granted Exception Requests” Web page for scenarios where exception request were denied or granted by CGS.

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