(Medicare Claims Processing Manual)

Within CWF, the episode history auxiliary file is separate from the home health benefit period auxiliary file (labeled HHEH), which existed prior to HH PPS and is used to administer payment of HH services from the correct Medicare Trust Fund.  All HH PPS claims update bot h these files.  NOAs only update the episode history file.   The initial 30 -day period of care is created on this file based on the NOA. The start date of this period of care is also used to indicate the start date of an HH admission period.  The HH admission period is a claims processing concept used to correctly e nforce primary HHA assignment and HH consolidated billing.   Medicare systems determine a claim to fall within an HH admission period if it is within an admission period start and end date OR if it is on or after the start date of a period that remains open. Medicare systems determine the span of an admission period from HHEH period information as follows:   Admission Period Start Date: The HHEH Period Start Date when the NOA indicator is 1 or 2.  Admission Period End Date:    The HHEH Period End Date when the patient status on latest HHEH period in a series of contiguous periods indicates a discharge (the code is other than 30), or   The HHEH Start Date of a subsequent HHEH period when the NOA indicator on the subsequent period is 1 or 2. If an NOA with a different provider number falls within an admission period and does not report a transfer using condition code 47, the NOA will be returned to the provider because the HHA is not the primary HHA for that beneficiary.   If a claim subject t o HH consolidated billing falls within an admission period, but does not fall within dates that reflect an HH claim has been paid, the claim will receive an alert as described in section 20.2.5.   The initial 30 -day period of care created by the NOA is updated by the claim for that period.  All subsequent periods of care in the admission will be created by the subsequent claims.   Multiple periods can be open for the same beneficiary at the same time.  The same HHA may require multiple periods be opened for the same beneficiary because of an unexpected readmission after discharge.  Multiple periods may also occur between different p roviders if a transfer situation exists.  CWF will post NOAs received with appropriate transfer and readmit indicators to facilitate the creation of multiple periods.    Same day transfers are permitted, such that a period of care for one agency can end on the same date as a period of care was opened by another agency for the same beneficiary.  Both HHAs services for this date will be approved for payment, without regard for whether the same HH disciplines (e.g. skilled nursing, physical therapy, etc.) from both HHAs provided services.   When periods of care are created from NOAs, CWF calculates a period end date that does not exceed the start date plus 29 days.  CWF will assure no period exceeds the maximum length under any circumstance, and will auto- adjust the period end date to shorten the period if needed based on subsequent NOA or claim submissions (i.e., shortened by transfer).   30.7 - RESERVED   (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  30.8 - RESERVED  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  30.9 - Coordination of HH PPS Claims Episodes With Inpatient Claim Types (Rev. 4312, Issued: 05- 23-19, Effective: 01 -01-20, Implementation: 08- 16-19)  Beneficiaries cannot be institutionalized and receive home health care simultaneously.  Therefore claims for institutional inpatient services (inpatient hospital, skilled nursing facility (SNF) and swing bed claims), have priority in Medicare claims editin g over claims for home health services.   If an HH PPS claim is received, and CWF finds dates of service on the HH claim that falls within the dates of an inpatient, SNF or swing bed claim (not including the dates of admission and discharge and the dates of any leave of absence), Medicare systems will reject the HH claim.  The HHA may submit a new claim removing any dates of service within the inpatient stay that were billed in error.   If the HH PPS claim is received first and the inpatient hospital, SNF or swing bed claim comes in later, but contains dates of service duplicating dates of service on the HH PPS claim, Medicare systems will adjust the previously paid HH PPS claim to non -cover the duplicated dates of service.   30.10  RESERVED  (Rev. 4312, Issued: 05- 23-19, Effective: 01 -01-20, Implementation: 08- 16-19)  30.11 - Exhibit: Chart Summarizing the Effects of NOA/Claim Actions on the HH PPS Episode File  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  The following chart summarizes basic effects of HH PPS claims processing on the episode record.  Even though under the PDGM, the HH unit of payment is a 30- day period of care, this file continues to be named the episode file in CWF and references to episode record below refer to periods of care.   Transaction  How CWF Is Impacted  How Other Providers Are Impacted  NOA   Opens an episode record using NOA From date to set Period Start Date    CWF uses Start Date to calculate admission period    Period End Date is automatically calculated to extend through 30th day    DOEBA and DOLBA are left blank   NOA indicator is set to 1    Other NOAs submitted during this open admission period will be rejected unless an indicator of a transfer or discharge/readmission is present    Transaction  How CWF Is Impacted  How Other Providers Are Impacted  NOA with condition code 47   Opens an episode record using NOAs From date to set Period Start Date    Period End Date is automatically calculated to extend through 30th day    DOEBA and DOLBA are left blank   The Period End Date (if later than the NOA From date) is automatically changed to reflect the NOAs from date.    NOA indicator is set to 2     CWF uses the new Start Date as the end date of the previous admission period.     The Period End Date created by the NOA or claim of the HHA the beneficiary is transferring from is automatically changed to reflect the "from" date on the NOA submitted by the HHA the beneficiary is transferring to.  The HHA the beneficiary is transferring  from cannot bill for services past the date of transfer.    Another HHA cannot bill during this episode unless another transfer NOA is submitted.  NOA Cancellation by Provider  (TOB 032D)   The episode record is deleted from CWF   No episode record is present to prevent NOA submission by another provider, making that provider the primary HHA for the dates of the episode  Claim (full 30-day period, patient status 30)  30-day record  is completed    Period End Date remains at the 30th day   DOEBA is updated to reflect first visit date in period    DOLBA is updated to reflect last visit date in episode    CWF considers the admission period still open.    Other NOAs submitted during this open period will be rejected unless an indicator of a transfer or discharge/readmission is present   Transaction  How CWF Is Impacted  How Other Providers Are Impacted  Claim (discharge with goals met prior to Day 30)   30-day record  is completed    Period End Date remains at the 30th day;    DOEBA is updated to reflect first visit date in episode    DOLBA is updated to reflect last visit date in episode    CWF uses the Period End Date as the end date of the admission period also.    Other NOAs submitted with From dates before the end date of this period will be rejected unless an indicator of a transfer or discharge/readmission is present    Claim (transfer)   Episode record completed    Period End Date reflects claim Through date;    DOEBA is updated to reflect first visit date in episode    DOLBA is updated to reflect last visit date in episode    CWF uses the Period End Date as the end date of the admission period also.   An NOA will be accepted if the From date is on or after period Through date  Claim Adjustment   No impact unless adjustment changes patient status to transfer or service lines are added or removed to change the DOEBA or DOLBA date.   No impact  Transaction  How CWF Is Impacted  How Other Providers Are Impacted  Claim Cancellation   The period is deleted from CWF unless an NOA indicator of 1 or 2 is present.   If an NOA indicator is present, the HIPPS code and DOEBA/DOLBA dates are removed but the period remains in the file.   No impact    40 - Completion of Form CMS -1450 for Home Health Agency Billing  (Rev. 3021, Issued: 08- 08-14, Effective: 01 -01-12, Implementation: 09- 08-14)  The Social Security Act at 1862 (a)(22) requires that all claims for Medicare payment must be submitted in an electronic form specified by the Secretary of Health and Human Services, unless an exception described at 1862 (h) applies.  The electronic form  required for billing home health services is the ASC X12 837 institutional claim transaction.  Since the data structure of the 837 transaction is difficult to express in narrative form and to provide assistance to small providers excepted from the electronic claim requirement, the instructions below are given relative to the data element names on the Form CMS -1450 hardcopy form.  Each data element name is shown in bold type.  Information regarding the form locator numbers that correspond to these data elem ent names is found in chapter 25.  Because claim formats serve the needs of many payers, some data elements may not be needed by a particular payer.  This section provides detailed information only for items required for Medicare home health claims.  Items not listed need not be completed although home health agencies may complete them when billing multiple payers.  In all cases, the provider is responsible for filing a timely claim for payment.  (See chapter 1.)   40.1 - Notice of Admission (NOA)                                                            (Rev. 12106; Issued: 06- 29-23, Effective: 01 - 01-24; Implementation:01 -02-24)   HHAs must send the NOA to the A/B MAC (HHH) by mail, electronic data  interchange (EDI), or direct data entry (DDE). EDI submissions require additional data not required by the NOA itself, to satisfy transaction standards. This data is described in a companion guide available on the CMS website. HHAs may voluntarily agree to adopt the companion guide and use it to submit EDI NOAs at any time.  The following data elements are required to submit an NOA under HH PPS.     Provider Name, Address, and Telephone Number   Required -  The minimum entry is the agencys name, city, State, and ZIP Code.  The post office box number or street name and number may be included.  The State may be abbreviated using standard post office abbreviations.  Five or nine -digit ZIP Codes are acceptable.  This information is used in connection with the CMS Certification Number to verify provider identity.   Type of Bill   Required -    032x -  Home Health Services under a Plan of Treatment   4th Digit  Definition   A Admission/Election Notice   D  Cancellation of Admission/Election Notice   Statement Covers Period (From -Through)   Required  The HHA reports the date of the first visit provided in the admission as the From date.  The Through date on the NOA must always match the From date.    Patient Name/Identifier   Required -  Patients last name, first name, and middle initial.   Patient Address   Required -  Patients full mailing address, including street number and name, post office box number or RFD, City, State, and ZIP Code.  Patient Birth Date   Required -  Month, day, and year of birth of patient.  Left blank if the full correct date is not known.   Patient Sex   Required -  M for male or F for female must be present.  This item is used in conjunction with diagnoses and surgical procedures to identify inconsistencies.  Admission/Start of Care Date   Required -  The Admission date on the NOA must always match the From date.     Condition Codes   Conditional. -   If the NOA is for a patient transferred from another HHA, the HHA enters condition code 47.