(Medicare Claims Processing Manual)

Group Code: CO  CARC: 272  RARC: N211  MSN: 41.17   When OASIS Assessments Cannot Be Submitted Within 24 Months  A Medicare beneficiary's entitlement date may sometimes be approved or changed retroactively.  Frequently, these cases result in services becoming covered for dates of service that are beyond the Medicare timely filing limit.  Retroactive entitlement is an established exception to the timely filing pe riod, so these claims may be submitted for payment (see Pub. 100- 04, chapter 1, section 70.7.2).  iQIES accepts assessments for up to 24 months from the assessment date.  In rare cases, a retroactive entitlement decision may extend back beyond this 24 month period.  Each 60-day assessment that cannot be submitted to iQIES because of the 24 month limit may correspond to up to 2 Medicare claims for 30- day periods of care.   To process the claims for these older dates of service, HHAs should contact their MAC to alert them to the situation and request any special instructions for the timing and coding of the claims.  In addition to any other special instructions, the HHA shall  submit the claims with a note in the Remarks field saying "OASIS over 24 months."   Upon receipt of the claims, the HH&H MAC shall take the following actions:    When the untimely claims are suspended to check for exception requests, confirm the dates of service are over 24 months from the occurrence code 50 date on the claim.   Temporarily turn off the edit that triggers the iQIES finder file, process the affected claims without sending them to iQIES, then turn the edit back on.   Use the manual recoding process to copy the provider submitted HIPPS code from the 0023 revenue code into the recoded HIPPS code field and set the payment indicator (IND) field to P so the claim bypasses the home health Grouper.  Monitor the claims for any Common Working File recoding edits that may apply and update first position of the HIPPS code on the claims as necessary to resolve the edits.   10.1.20 - RESERVED  (Rev. 2230, Issued: 05- 27-11, Effective: 08 -28-11, Implementation: 08- 28-11)  10.1.21 - Payment Adjustments - Outlier Payments  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  HH PPS payment groups are based on averages of home care experience.  When cases lie outside expected experience by involving an unusually high level of services in 30-day periods of care, Medicare claims processing systems will provide outlier payments in addition to the case -mix adjusted payment.  Outlier payments can result from medically necessary high utilization in any or all of the service disciplines.   Outlier determinations are made by comparing:    The estimated cost for a period of care, calculated as the sum of the products of number of units of each discipline on the claim and each wage -adjusted national standardized per unit rate for each discipline (1 unit = 15 minutes); with   The sum of the period payment and a wage -adjusted standard fixed loss threshold amount.  If the estimated cost is greater than the wage adjusted and case- mix specific payment amount plus the wage adjusted fixed loss threshold amount, a set percentage (the loss sharing ratio) of the amount by which the estimated cost exceeds the sum will be pai d to the HHA as an outlier payment.  Units considered for outlier payment are subject to a limit of 32 units (8 hours), summed across the six disciplines of care, per date of service.   For rare instances when more than one discipline of care is provided and there is more than 8 hours of care provided in 1 day, the cost associated with the care provided during that day will be calculated using a hierarchical method based on the cost per unit per discipline.  The discipline of care with the lowest associated cost per unit will be discounted in the calculation of cost in order to cap the estimation of cost at 8 hours of care, summed across the six disciplines, per day.   The outlier payment is a payment for an entire period, and therefore carried only at the claim level on the paid claim.  It is not allocated to specific lines of the claim.   HHAs do not submit anything on their claims to be eligible for outlier consideration.  The outlier payment shall be included in the total payment for the claim on a remittance, but it will be identified separately on the claim using value code 17 with an associated dollar amount representing the outlier payment. Outlier payments will also appear on the electronic remittance advice in a separate segment.    Outlier payments made to each HHA are subject to an annual limitation.  Medicare systems ensure that outlier payments comprise no more than 10 percent of the HHAs total HH PPS payments for the year.  Medicare systems track both the total amount of HH PPS payments that each HHA has received and the total amount of outlier payments that each HHA has received.  When each HH PPS claim is processed, Medicare systems compare these two amounts and determine whether the 10 percent has currently been met.  If the limitation has not yet been met, any outlier amount is paid normally.   If the limitation has been met or would be exceeded by the outlier amount calculated for the current claim, other HH PPS amounts for the claim are paid but any outlier amount is  not paid.  Partial outlier payments are not made.    The contractor shall use the following remittance advice messages and associated codes when not paying outlier amounts under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 119  RARC: N/A  MSN: N/A  Since the payment of subsequent claims may change whether an HHA has exceeded the limitation over the course of the timely filing period, Medicare systems conduct a quarterly reconciliation process.  All claims where an outlier amount was calculated but not paid when the claim was initially processed shall be reprocessed to determine whether the outlier has become payable.  If the outlier can be paid, the claim is adjusted to increase the payment by the outlier amount.  Additionally, if any HHAs are found t o have been overpaid outlier during the quarterly reconciliation process, claims are adjusted to recover any excess payments.  These adjustments appear on the HHAs remittance advice with a type of bill code that indicates a contractor -initiated adjustment (TOB 032I) and the coding that typically identifies outlier payments.  This quarterly reconciliation process occurs four times  per year, in February, May, August and November.   10.1.22 - RESERVED  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  10.1.23 - Changes in a Beneficiarys Payment Source  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  1. Payment Source Changes From Medicare Advantage (MA) Organization to Original Medicare.   If a Medicare beneficiary is covered under an MA Organization during a period of home care, and subsequently decides to change to Original Medicare coverage, a new start of care OASIS assessment must be completed that reflects the date of the beneficiarys change to this pay source.  This is required any time the payment source changes to Original Medicare.  With that assessment, an NOA may be sent to  Medicare to open an HH PPS admission period.  HHAs are advised to verify the patients payer source on a regular basis when providing services to a patient with an MA Organization payer source to avoid the circumstance of not having an OASIS to be used to determine the payment group, or having the patient discharged without an OASIS assessment.  If a follow -up assessment is used to generate a new start of care assessment, CMS highly recommends, but does not require, a discharge OASIS assessment be done.   While this is not a requirement, conducting a paper discharge at the point where the patients change in insurance coverage occurred will provide a clear endpoint to the patients episode of care for purposes of the individual HHAs outcome -based quality reports.  Otherwise, that patient will not be included in the HHAs quality measure statistics.  It will also keep that patient from appearing on the HHAs roster report (a report the HHAs can access from the OASIS system that is helpful for tracking OASI S start of care and follow -up transmissions) when the patient is no longer subject to OASIS data collection.   In cases where the patient changes from MA coverage to Original Medicare coverage, the patients overall Medicare coverage is uninterrupted.  This means an HH PPS period of care may be billed beginning on the date of the patients Original Medicare coverag e.  Upon learning of the change in MA election, the HHA should submit an NOA using the date of the first visit provided after the Original Medicare effective date as the from date.  The OASIS assessment performed most recently after the change in electio n is used to produce a HIPPS code for the first claim in the new admission period.   If a new start of care (SOC) OASIS assessment was not conducted at the time of the change in pay source, a correction to an existing OASIS assessment may be necessary to change the reported payer source.  The HHA should correct the existing OASIS assessmen t conducted most closely after the new start date.  If more than one 30- day period has elapsed before the HHA learns of the change in payer source, this procedure can be applied to the additional periods.  If the patient is still receiving services, the HH A must complete the routine follow -up OASIS assessments (RFA4) consistent with the new start of care date.  In some cases, HHAs may need to inactivate previously transmitted assessments to reconcile the data collections with the new dates.   2. Payment Source Changes From Original Medicare to MA Organization  In cases where the patient elects MA coverage during an HH PPS period of care, the period will end and be proportionally paid according its shortened length (a partial period payment adjustment).  The MA Organization becomes the primary payer upon the MA enrollment date.  The HHA may learn of the change after the fact, for instance, upon rejection of their claim by Medicare claims processing systems.  The HHA must resubmit this claim indicating a transfer of payer source using patient status code 06, and reporting only the visits provided under the fee -for-service eligibility period.  The claim through date and the last billable service must occur before the MA enrollment date.  If the patient has elected to move from Original Medicare to an MA Organizatio n and is still receiving skilled services, the HHA should indicate the change in payer source on the OASIS at the next assessment time point.   3. Payment Source Changes Involving Medicaid   There may be cases where a patient eligible for both Medicare and Medicaid is receiving home health services covered under Medicaid and the patient experiences a change in status that allows their home health services to meet coverage criteria for Original Medicare.  In these cases, a new start of care OASIS assessment must be completed that reflects the date of the beneficiarys change to this pay source.  This is required any time the payment source changes to Original Medicare.  With that assessment, an NOA may be sent to Medicare to open an HH PPS admission period.  The OASIS guidance provided above for changes from Medicare Advantage to Original Medicare apply in this case also.   If a patient eligible for both Medicare and Medicaid is receiving home health services covered under Medicare and ceases to meet Medicare coverage criteria, the patient should be discharged for Medicare purposes.  Patient status code 06 should not be use d.  This discharge has no payment impact on the Medicare HH PPS period.  If the patient being discharged to Medicaid- only coverage is still receiving skilled services, the HHA should indicate the change in payer source on the OASIS at the next assessment.  10.1.24 - Glossary and Acronym List  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  ABN -  Advance Beneficiary Notice of Non -Coverage   Admission Date -  For HH PPS, the date of the first service delivered by the HHA in a period of care or a series of continuous periods.  It is placed in the Admission/Start of Care Date field on the institutional claim.   Admission Period  The period between the From date of a Notice of Admission and the discharge date.  An admission period may contain several 30- day periods of care and their corresponding claims.   A/B MAC (A) -  A/B MACs processing hospital claims.   A/B MAC (HHH) -  A/B MACs processing all Home Health and Hospice claims.   CBSA -  Core Based Statistical Area   CCN -  CMS certification number   Claim -  The transaction submitted to receive payment for an HH PPS 30- day period of care.   CLIA - Clinical Laboratory Improvement Amendments   CMS -  The Center for Medicare & Medicaid Services, the Federal Agency administering the Medicare program.   CWF -  Common Working File   DCN -  Document Control Number   DME -  Durable Medical Equipment.