October 22, 2015

Reported by: Theresa Forster, National Association for Home Care & Hopsice

Recently National Association for Home Care and Hospice (NAHC) received two clarifications  on issues from CMS to the MACs related to NOEs/NOTRs.  Both issues raised by NAHC with CMS staff were out of concern that they could result in problems for hospice providers.  The issues are as follow:

1.     NAHC heard from hospices that when an error related to the benefit period dates was entered on an NOTR, correcting the NOTR required that the hospice back out the NOTR, all claims associated with the benefit period, and the NOE.  When the NOE was resubmitted, the MACs were not permitting an exception to the “timely filing” requirement and were denying payment for all services associated with the claims during the period.  NAHC raised the issue with CMS and we were informed that the issue would be addressed.  Today CGS issued notice that, in response to clarification from CMS to the MACs, they have modified their information related to the exceptions process for a late NOE.  CMS has also clarified that an exception will be granted in cases where an individual receives retroactive Medicare entitlement, provided supporting documentation is provided. 

Following is an excerpt from the CGS’ website, with policy changes highlighted: 

Four Exceptions
Medicare guidelines allow for four exceptions if a hospice NOE is not filed timely.

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
• An exception will be granted in situations when supporting documentation shows that the NOTR was submitted with an incorrect discharge date, causing all previously submitted claims and the original NOE to be canceled (backed out).  Because of the limitation of the claims processing system, this situation is beyond the hospice’s control.  Note: If the original NOE was not timely-filed, the original payment liability will stand.

NOTE: CMS provided further direction regarding an individual who receives retroactive Medicare entitlement. A retroactive Medicare entitlement qualifies as one of the exceptions if a hospice NOE is not filed timely. However, the exception will only be granted with supporting documentation. Refer to the “Requesting an Exception” section further down on this page for details.

Following is a link to CGS’ information on exceptions to the timely filing requirement:  http://cgsmedicare.com/hhh/education/materials/requesting_exception_untimely_noes.html  

2. NAHC also raised concerns with CMS related to varying MAC requirements relative to inclusion of the principal diagnosis on the NOTR (two of the HHH MACs did NOT require the principal diagnosis on the NOTR while one did require it).  We were concerned that with the advent of ICD10 this would create additional potential for failure to meet the timely filing requirements for the NOTR if the hospice used the wrong code set.  CMS has provided clarification on this issue to the MACs and in recent days, instructions on all of the MAC websites indicate that A PRINCIPAL DIAGNOSIS IS NOT REQUIRED ON THE NOTR.  It should be noted that if a hospice DOES include a principal diagnosis on the NOTR, and uses the incorrect code set, the NOTR will be returned to provider.