License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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

End User License Agreement

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May 11, 2021

Appeal Requests on Home Health Exceptions For an Untimely RAP

CGS has seen an increase of redeterminations, (1st level of appeal) being submitting without first requesting an exception for an untimely request for anticipated payment (RAP). A redetermination is not acceptable if an exception has not yet been submitted. When a redetermination requests is submitted without having an exception request, CGS will return the appeal request.

When a RAP is submitted untimely, the first step is to request an exception. To request an exception, submit the KX modifier on the final claim Health Insurance Prospective Payment System (HIPPS) code on the revenue code 0023 line. In addition, you must include information in the REMARKS field documenting how the following circumstances caused the RAP to be submitted untimely. If the information in the REMARKS field is not clear, a non-medical review additional development (non-MR ADR) request will be issued to obtain more information.

Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA's ability to operate
An event that produces a data filing problem due to a CMS or MAC systems issue that is beyond the control of the HHA
A newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC
Other circumstances determined by the MAC or CMS to be beyond the control of the HHA.

If the final claim was submitted without the KX modifier, and you wish to request an exception, you may submit an adjustment (type of bill XX7) or a reopening request (type of bill (XXQ) and add the KX modifier and information in the REMARKS field.

Exception Request Outcome

When an exception is requested, and the review of the information provided in the REMARKS field, or the submitted documentation does not qualify for the exception to be granted, the penalty will still apply. At that point, the home health agency may appeal the penalty amount applied to the final claim. Refer to the 1st Level of Appeal – Redetermination web page for additional information.

Resources:

What You Need to Know About the Home Health RAP Penalty, CGS article
MM11855, Penalty for Delayed Request for Anticipated Payment (RAP) Submission – Implementation.
Submitting a Final Claim under the Home Health Patient-Driven Groupings Model CGS web page
1st Level of Appeal – Redetermination CGS web page