(Medicare Claims Processing Manual)

20.2.3 - Other Editing Related to Home Health Consolidated Billing  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  CWF edits to prevent duplicate billing across two providers.  Consequently, CWF must edit to ensure that all DME items billed by HHAs have a line -item date of service and HCPCS code, even though HH consolidated billing does not apply to DME by law.  If revenue code 0636 and the HCPCS code for an osteoporosis drug is billed on a TOB 034x claim during an open HH period of care, CWF ensures that the provider of the 034x claim is the same as the primary provider of the open period of care, since by law consolidated billing must also be applied to the osteoporosis drug even though this item is paid outside of the unit of payment.  HH consolidated billing will not affect billing of DME or services outside the home health benefit, even when these services are billed by HHAs.   20.2.4 - Only Notice of Admission (NOA) Received and Services Fall Within Admission Period  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  If only an NOA has been received and the incoming claim with services subject to consolidated billing contains dates of service within the HH admission period, CWF returns an alert to the Medicare contractor to notify them that the claim may be subject to consolidated billing.  The Medicare contractor processes the claim to payment, but passes on the alert to the provider on the remittance advice at the line level.   The contractor shall use the following remittance advice messages and associated codes when making payment under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.   Group Code: CO  CARC: N/A  RARC: N88  MSN: N/A  This indicates to providers that the services may be denied and claim payment may be recouped if later editing or another post -payment recovery process identifies the claim as subject to consolidated billing.   20.2.5 - No NOA Received and Therapy Services Rendered in the Home  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  There may be situations in which a beneficiary is under a home health plan of care, but CWF does not yet have a record of either an NOA or a home health claim for the period of care.  To help inform independent therapy providers billing professional claims  to Medicare contractors that the services they rendered in the home setting may be subject to consolidated billing, providers will receive notification on the remittance advice when Medicare pays them for the service.   Medicare systems processing professional claims will provide this notification when the place of service on the claim is 12 home, the HCPCS code is a therapy code subject to home health consolidated billing and CWF has not returned a message indicating t he presence of an NOA.   30 - Common Working File (CWF) Requirements for the Home Health Prospective Payment System (HH PPS)  (Rev. 1, 10- 01-03) HH- 468, A3- 3640  30.1 - Eligibility Query to Determine Status (Rev. 10758; Issued: 05 -11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Under the HH PPS and home health consolidated billing one HHA is considered the primary home health agency in billing situations.  This primary agency is the only agency that may bill Medicare for home care for a given homebound beneficiary at a specific time.  When a homebound beneficiary seeks care from an HHA or from an institutional therapy provider subject to home health consolidated billing, the provider needs to determine if the beneficiary is already being served by an HHA -  an agency that then would be considered primary.   Providers may send an inquiry to determine the beneficiarys entitlement and eligibility status into the Common Working File or CWF, through their A/B MAC (A) or (HHH).  They must send the ASC X12 270 Health Care Eligibility Inquiry transaction set and wil l receive the ASC X12 271 Health Care Eligibility Response transaction set in response, in order to comply with the requirements of the Health Insurance Portability and Accountability Act.   A/B MACs (A) or (HHH) processing institutional claims will create an ELGH record from the 270 to request this data from CWF and will receive the ELGA record from CWF in response.  The A/B MAC (A) or (HHH) will create the 271 response or DDE screen from the  ELGA transaction record.   The response shows whether or not the beneficiary is currently in a home health admission period.  If the beneficiary is not already under care at another HHA, he/she can be admitted to the inquiring HHA, and that agency will become primary.  The beneficia ry can also be admitted even if an admission period is already open at another HHA if the beneficiary has chosen to transfer.   See chapter 31 for a description of the data elements and related requirements.  30.2 - CWF Response to Inquiry  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  CWF will return information on the two periods of care in the CWF episode file closest to the date the HHA or other provider entered in the applicable date field.  If a date is not specified, information on the two most recent periods of care will be returned.  See Chapter 31 for complete data sets returned to specific provider types.   30.3 - Timeliness and Limitations of CWF Responses  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Inquirers receive a response within a very short time frame.  However, these responses are not truly real time.  The CWF auxiliary file that retains admission period and period of care information is updated by, and is only as current as, each NOA or cla im batch run in CWF.  All processed NOAs and claims will update the file, even if claims are ultimately denied.  The CWF removes periods from the file only when:    HHAs cancel their own NOA for a period of care that includes no subsequent claims;   HHAs cancel their own claims for periods that were not initially created by an NOA; or    When a A/B MAC (HHH) processing HH claims cancels an NOA or a claim for specific reasons (i.e., fraud).  In general, responses will be as current as the previous day.  Therefore, even when a response indicates a beneficiary is not currently in an admission period, the possibility exists that an NOA or claim could be in process, and the inquiring agency would still not be the primary HHA for a beneficiary for whom a clear inquiry was received.  In such cases, the inquiring agency will not learn that it is not the primary HHA immediately.   Also possible but even more rare, NOAs or claims from two different HHAs for the same beneficiary for the same date may be in the same batch sent to CWF.  In such cases, the claim process will result in one of the two transactions being processed first and thereby deciding which of the two agencies will be primary.  30.4 - Provider/Supplier Inquiries to MACs  Based on Eligibility Responses  (Rev. 1348, Issued: 10- 05-07, Effective: 01 -01-08, Implementation: 11- 05-07)  Institutional providers and/or suppliers may want to follow -up on information they receive, usually to contact the primary agency on file to bill under arrangement.  The provider or supplier may determine the HHAs A/B MAC (HHH) from the CMS Web site which has a list of A/B MACs (HHH) that process HH claims by State.  The provider or supplier also may ask its own MAC through existing provider inquiry channels.  That MAC will instruct the provider regarding which A/B MAC (HHH) that processes HH claims to contact to learn which HHA is involved.   A/B MACs (HHH) that process HH claims may provide information on either the provider or A/B MAC (HHH) that these providers may request.  Information released will be determined by each MAC, such as HHA name and address, but must be enough for the inquiring provider/supplier to contact either the primary HHA, if under that A/B MAC (HHH)s jurisdiction, or another A/B MAC (HHH), if the provider number is attached to another A/B MAC (HHH).  If an instance ever exists where a provider is an individual, such as a provider doing business using a Social Security Number as a tax identification number, information cannot be released, since it would violate the individuals right to privacy.   30.5 - National Home Health Prospective Payment Episode History File  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  CWF maintains a national history file for each beneficiary in order to enforce consolidated billing and perform HH PPS processing.  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.  Only MACs, not providers, may view this file.   The episode file, populated as soon as an admission period is opened for a beneficiary with an NOA, contains:    The beneficiary identifier;    Period Start and End Dates  - the start date is received on an NOA or claim, and the end date is initially calculated to be the 30th day after the start date, changed as necessary when the claim for the period is finalized;    The pertinent A/B MAC (HHH), CMS Certification Number and National Provider Identifier ;   The HRG Code -  the HIPPS code used to determine payment for the period of care;    Date of Earliest Billing Activity (DOEBA) and Date of Latest Billing Activity (DOLBA) line item dates of service of the first and last HH visits reported on the claim for the period of care;    Patient Status Indicator - the patient discharge status code on an HH PPS claim, indicating the status of the HH patient at the end of the period of care.     Cancellation Indicator  Indicates if the claim has been denied as fully non -covered by medical review.  In these cases, the indicator is a value of 2.  In all other cases, the value is 0.    NOA Indicator  Indicates the period was initially created by an NOA, not a claim.   If the NOA is submitted as a transfer, with condition code 47, this indicator is set to 2. For any other NOAs, this indicator is set to 1.  If a period is created by a continuing claim, this indicator is blank.   The episode file contains the 36 most recent periods of care for any beneficiary.  Periods that precede the most recent 36 will be dropped off the file and will not be retrievable online.   30.6 - Opening and Length of HH PPS Episodes /Periods of Care  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  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: