Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from March 16, 2021, to April 14, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for insufficient information regarding the decision. The Plan requested a reopen and provided additional information. The Plan demonstrated that the enrollee had a continuous episode of care with the provider from March 16, 2021, to April 26, 2021, as evidenced in the claim for date of service March 16, 2021, to April 14, 2021, and in the claim for date of service April 15, 2021 to April 26, 2021. Per Medicare Claims Processing Manual Chapter 10, Section 10.1.15, both transfer situations and discharge and readmission to the same agency in a 30-dayperiod result in shortened periods of care. In such cases, payment will be pro-rated. Partial period payment adjustments occur as a result of the two following situations: a. When a patient has been discharged and readmitted to home care within the same 30-day period of care, or b. When a patient transfers to another HHA during a 30-day period of care. Both situations are indicated on the claim by reporting a Patient Discharge Status code of 06. Based on the presence of this code, Pricer calculates a partial period payment adjustment to the claim. This is a proportional payment amount based on the number of days of service provided, which is the total number of days counted from and including the day of the first billable service to and including the day of the last billable service, divided by 30. The provider billed the claim with a date span of March 16, 2021, to April 14, 2021, and a Patient Discharge Status code of 06. As neither scenario A nor B in the above Medicare guideline applied, the discharge status code of 06 billed on the claim is incorrect.
The claim history shows the enrollee had a continuous episode of care with the provider from March 16, 2021, to April 26, 2021. The billing of the Discharge Status Indicator 6 is not justified because: 1) Scenario A would not apply since the member was not discharged and readmitted within the same 30-day period as evidenced by the continuous episode of care with no gaps in service. 2) Scenario B would not apply as both claims show the member had continuous care with the provider and was not transferred to another home health agency during the 30-day period of care listed on the claim in question. As neither of the scenarios that justify a discharge status code of 6 applied, the provider's billing of the discharge status code of 6 is incorrect.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, this claim was billed with an incorrect status code of 6, based on the records provided and the dates of service. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from March 16, 2021, to April 14, 2021.