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###### Department of Health and Human Services

###### Health Care Financing Administration 

          - [Document Identifiers: HCFA-R-296 (OMB # 0938-0781)] 

# AGENCY:

Health Care Financing Administration, DHHS. 

                        The Health Care Financing Administration (HCFA), Department of Health and Human Services, is publishing this Notice to inform the public that the Office of Management and Budget (OMB) has approved our request for an extension of the OMB clearance on model advance beneficiary notices (ABNs), for which we first requested emergency clearance by                         **Federal Register**                         notice dated September 22, 1999 (HCFA-R-296, OMB # 0938-0781). Clearance of these model ABNs (referred to as HHABNs) for use by home health agencies (HHAs) has been extended through January 31, 2001. These model notices, together with the instructions in Program Memorandum Transmittals A-99-52 and A-99-54, remain in effect following the implementation of the prospective payment system (PPS) for home health agencies on October 1, 2000. HCFA also has published a                         **Federal Register**                         notice on September 26, 2000, 65 FR 57821, seeking emergency OMB clearance, pursuant to the Paperwork Reduction Act, of a revised uniform Home Health Advance Beneficiary Notice (HHABN), which we expect to make mandatory in January 2001.                     

*Use:*                         The purpose of this Notice is to clarify, for Medicare beneficiaries, for HHAs, and for other interested members of the public that existing requirements regarding notice and demand bills, as set forth in Program Memorandum Transmittals A-99-52 and A-99-54, and as reflected in the model notices for which OMB has extended the emergency clearance, remain in effect following the implementation of the prospective payment system for HHAs on October 1, 2000. Thus, in accordance with the instructions in PMs A-99-52 and A-99-54, HHAs continue to be responsible for providing proper ABNs and for submitting demand bills to Regional Home Health Intermediaries (RHHIs) when requested to do so by a beneficiary or by a person acting on the beneficiary's behalf. Moreover, the transition to PPS does not change HHAs' responsibility to follow ABN and demand bill procedures for plans of care in which the physician's order spans the transition.                     

HHAs must give a Medicare beneficiary a proper ABN before reducing or terminating home health care the beneficiary already is receiving, if the physician's order for such care would still continue the care, and an HHA believes that the services do not meet Medicare coverage criteria. In instances where care has not yet been initiated and an HHA believes services ordered by the physician do not meet Medicare coverage criteria, it must also provide a proper ABN. Currently, HHAs may use the model HHABNs designed by HCFA (Form No. HCFA-R-0296) or forms of the HHA's own design to meet the beneficiary notification requirement. 

### Continued Use of Demand Billing Procedures and Meaning of “Prompt” Submission Under HHA PPS 

With respect to the instructions regarding demand bills in Transmittals A-99-52 and A-99-54, we want to emphasize that the demand bill process remains in effect following the implementation of HHA PPS, and must be used by HHAs to ensure continuation of beneficiary rights to obtain an official Medicare initial determination. Beginning in June, HCFA has been assessing the operational feasibility and impact of options for integrating the initial determination process into HHA PPS. In the HHA PPS final rule published on July 3, 2000, we stated, in response to public comment, that HCFA was reviewing demand billing procedures to determine whether they must be modified to account for the differences between HHA reasonable cost billing and HHA PPS. 65 FR 41128, 41169 (July 3, 2000) (Medicare Program; Prospective Payment System for Home Health Agencies, Final Rule). As a result of our assessment of the feasibility of various options, HCFA decided to continue to use the demand bill process as the mechanism by which Medicare beneficiaries obtain an official Medicare initial determination when an HHA believes, under HHA PPS, that Medicare will not, or will no longer, cover services ordered by a physician. 

                    When a beneficiary agrees to be fully and personally responsible for payment for the services if Medicare decides the services are not covered, and has requested that a claim be submitted to Medicare, HHAs must “promptly” submit a claim to the RHHI and report, on the claim submitted, condition code 20 (demand-beneficiary requested billing) to indicate the beneficiary believes the services are covered (                    *see*                     PM A-99-52 sec. I-2A). Under HHA PPS, HHAs may submit only one claim for payment at the end of each episode of care.                     *See*                     65 FR at 41141. Thus, under HHA PPS, “prompt submission” of a claim with the demand bill code requires that the claim (                    *i.e.,*                     the demand bill) be submitted at the end of the episode in question, at the same time the claim for final payment for the episode is submitted. Pursuant to the HHA PPS Final Rule, where an HHA has received a “request for anticipated payment” (RAP) for an episode, the RAP will be canceled and recovered unless the claim for the episode (with the condition code 20 to indicate that the claim is a demand bill when requested by the beneficiary in the circumstances described in PM A-99-52) is submitted within the greater of 60 days from the end of the episode or 60 days from the issuance of the anticipated payment. 65 FR at 41141.                 

### Future Plans 

                    As noted above, on September 26, 2000, HCFA published a                     **Federal                               ( print page 59859)                            Register**                     notice seeking emergency OMB clearance, pursuant to the Paperwork Reduction Act, of a revised uniform mandatory Home Health Advance Beneficiary Notice (HHABN). (The                     **Federal Register**                     notice, which includes procedures for submitting comments on the revised HHABN, the revised uniform HHABN and related documents, including a Supporting Statement, are posted on HCFA's website at                     *http://www.hcfa.gov/​regs/​prdact95htm,*                     and are also available via an e-mail request sent to Paperwork@hcfa.gov). HCFA has requested that OMB issue an emergency clearance of the proposed uniform HHABN by October 12, 2000, and HCFA intends to make mandatory the use of the HHABN not later than 90 days following OMB approval. (See the Supporting Statement for HCFA-R-0296). The instructions and requirements of PMs A-99-52 and A-99-54 will remain in effect until a further instruction with a new mandatory implementation date is issued. HCFA expects to issue these instructions as soon as it receives emergency approval by the Office of Management and Budget (OMB). HCFA strongly advises that HHAs use the new notice (the HHABN) once it is approved and instructions are issued, rather than waiting until its use becomes mandatory in January 2001.                 

Dated: October 4, 2000. 

John P. Burke III, 

HCFA Reports Clearance Officer, HCFA, Office of Information Services Security and Standards Group Division of HCFA Enterprise Standards.

[FR Doc. 00-25936 Filed 10-6-00; 8:45 am] 

BILLING CODE 4120-03-P