evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Required - The HHA enters the name and national provider identifier (NPI) of the attending physician who signed the plan of care.   Other Provider (Individual) Names and Identifiers   Required -  The HHA enters the name and NPI of the physician who certified/re -certified the patients eligibility for home health services.   NOTE:  Both the attending physician and other provider fields should be completed unless the patients designated attending physician is the same as the physician who certified/re -certified the patients eligibility.  When the attending physician is also the certifying/re -certifying physician, only the attending physician is required to be reported.   Remarks   Conditional  If the NOA that corresponds to a claim was filed late and the HHA is requesting an exception to the late -filing penalty (see section 10.1.10.3), enter information supporting the exception category that applied to the NOA.   The HHA shall provide sufficient information in the Remarks section of its claim to  allow the contractor to research the case. If the remarks are not sufficient, Medicare  contractors shall request documentation. Documentation should consist of printouts or  screen images of any Medicare systems screens that contain the information shown  above.   Medicare contractors shall not grant exceptions if:   the HHA can correct the NOA without waiting for Medicare systems actions   the HHA submits a partial NOA to fulfill the timely -filing requirement, or   HHA with multiple provider identifiers submit the identifier of a location that did not actually provide the service   In the great majority of cases, the five day timely filing period allows enough time to  submit NOAs on a day when Medicare systems are available (i.e.  the period allows for  ("dark days"). Additionally, the receipt date is typically applied to the NOA immediately  upon submission to Medicare systems, so subsequent dark days would not affect the  determination of timeliness. However, if the HHA can provide documentation showing an NOA is submitted on the day before a dark day period and the NOA does not receive a  receipt date until the day following the dark days, the contractor shall grant an exception to the timely filing requirement. CMS expects these cases to be very rare.
(Medicare Claims Processing Manual)
Remarks are otherwise required only in cases where the claim is cancelled or adjusted.  adjusted.  40.5  RESERVED  (Rev. 4312, Issued: 05- 23-19, Effective: 01 -01-20, Implementation: 08- 16-19)  50 - Beneficiary -Driven Demand Billing Under HH PPS  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Demand billing is a procedure through which beneficiaries can request Medicare payment for services that: (1) their HHAs advised them were not medically reasonable and necessary, or that (2) they failed to meet the homebound, intermittent or noncustodial care requirements, and therefore would not be reimbursed if billed.  The HHA must inform the beneficiary of this assessment in an Advance Beneficiary Notice of Noncoverage (ABN), which also must be signed by the beneficiary or appropriate representative.  I nstructions for the ABN are found in chapter 30 of this manual.  Beneficiaries pay out of pocket or third party payers cover the services in question, but HHAs in return, upon request of the beneficiary, are required to bill Medicare for the disputed services.  If, after its review, Medicare decides some or all the disp uted services received on the demand bill are covered and pays for them, the HHA would refund the previously collected funds for these services.  If the Medicare determination upholds the HHAs judgment that the services were not medically reasonable and necessary, or that the beneficiary failed to meet the homebound or intermittent care requirements, the HHA keeps the funds collected, unless the A/B MAC (HHH) determines the ABN notification was not properly executed, or some other factor changed liabilit y for payment of the disputed services back to the HHA.    A. Interval of Billing   The Medicare payment unit for home care under the home health prospective payment system (HH PPS) is a period of care, usually 30 days in length.  A Notice of Admission (NOA) must be submitted for a beneficiary before any claims can be processed.  A claim is submitted for every 30 days of HH services.  This does not change in demand bill situations.   B. Timeliness of Billing
(Medicare Claims Processing Manual)
B. Timeliness of Billing   Medicare requests that HHAs submit demand bills promptly.  Timely filing requirements apply to HH PPS claims in the same manner as other claims (see chapter 1 for information on timely filing).  Medicare has defined promptly for HH PPS to mean submission at the end of the period of care in question.  The beneficiary must also be given either a copy of the claim or a written statement of the date the claim was submitted.   C. Claim Requirements   HH PPS claims, including demand bills, are submitted with TOB 0329, and provide all other information required on that claim for the HH PPS period of care, including all visit- specific detail.  The HHA must NOT use TOB 0320 when submitting a demand bill.  The HHA must report condition code 20 and the services in dispute shown as noncovered line items.  Demand bills may be submitted with all noncovered charges.  Provision of this additional information assures medical review of the demand bill.    Cases may arise in which the services in dispute are visits for which an HHA has physicians orders, but the duration of the visits exceeds Medicare coverage limits.  However, the portion of these visits that is not covered by Medicare may be covered by another payer (e.g., an 8- hour home health aide visit in which the first 2 hours may be covered by Medicare and the remaining 6 hours may be covered by other insurance).  In such cases, HHAs must submit these visits on demand bills as two line items.  One line will represent the portion potentially covered by Medicare with a covered charge amount and units reporting the Medicare -covered visit time.  The second line will represent the portion to be submitted for consideration by other insurance with a noncover ed charge amount and units reporting non- Medicare visit time.    Cases may also arise in which a State Medicaid program requests the demand bill on the beneficiarys behalf regarding services which have been billed to Medicaid.  In these cases, the dates of service for which the State requests the demand bill may not correspond exactly to the periods billed to Medicare.  These cases require special instructions:   Requests regarding services not expected to be billed to Medicare:
(Medicare Claims Processing Manual)
Requests regarding services not expected to be billed to Medicare:   A Medicare- Medicaid dually -eligible patient may be admitted to home care with the expectation that no services will be billed to Medicare.  Later, the State may request demand bills beginning during the course of that care.  This may occur when requests correspond to a calendar year.  For example, the patient may be admitted in December and the request for demand bills is effective January 1.  In this case, the HHA should submit a demand bill to Medicare with period of care dates that began in December.  Al l services should be submitted as non- covered line items.  As with any demand bill, condition code 20 should be reported on this claim.   Request applies to services immediately following Medicare discharge:   A dually- eligible patient may be discharged from Medicare home health services before the end of a 30 -day period of care due to the patient meeting their treatment goals.  The patient may remain under the care of the HHA receiving services billed to Medica id.  States may vary in their requirements for a new Start of Care OASIS assessment in these cases.   If the State requesting a demand bill for the services within the original 30 -day period of care does not require a new OASIS assessment, the HHA should submit an adjustment to their previously paid Medicare claim, using TOB 0327.  The HHA should add condi tion code 20 to the adjustment claim, change the statement Through date to reflect the full 30-day period and add the services provided during the demand bill request period as non-covered line items.  The HHA should then submit claims with condition code 20 and all non- covered line items for any periods of continuous care within the demand bill request period.   If the State requesting a demand bill for the services within the 30- day period of care requires a new OASIS assessment, the HHA should submit an NOA and submit claims with condition code 20 as they would for any other demand bill situation.  When Medicare receives the NOA for the demand billed episode it will cause a partial period payment adjustment to apply to the prior period.  Medicare cannot presume that the demand billed period will or will not be covered based on the NOA.  If the claim for the deman d billed period is later reviewed and found to be entirely non- covered, Medicare systems will automatically adjust the prior period to restore the appropriate full episode payment.  D. Favorable Determinations and Medicare Payment
(Medicare Claims Processing Manual)
Results of Medicare determinations favorable to the party requesting the demand bill will not necessarily result in increased Medicare payment.  In such cases, and even if a favorable determination is made but payment does not change, HHAs will still refund any monies collected from beneficiaries or other payers for services previously thought not medically necessary under Medicare.  Medicare payment will change only with the addition of covered visits if one or more of the following conditions apply:    An increase in the number of overall visits that either:   1. Changes payment from a low -utilization payment adjustment to a full period payment; or   2. Results in the period of care meeting the threshold for outlier payment.    A favorable ruling on a demand bill adds days to a claim paid a partial period payment adjustment.  If a favorable determination is made, A/B MACs (HHH) will assure pricing of the claim occurs after medical review so that claims also serving as demand bills receive appropriate payment.   E. Appeals   Appeal of Medicare determinations made on HH PPS claims also serving as demand bills is accomplished by appealing the HH PPS claim.  Such appeals are done in accordance with regulations stipulating appeals rights for Medicare home health claims.     F. Specific Demand Billing Scenarios   1. Independent Assessment -- Billing questions relative to the ABN and home health assessments.  With regard to  payment liability for the assessment itself, the assessment is a non- covered service that is not a Medicare benefit and is never separately payable by Medicare.  In all such cases, a choice remains:  The provider may or may not decide to hold the benefici ary liable, and Medicare cannot specify which is appropriate because the service at issue is outside Medicare's scope.   If a decision is made to hold a beneficiary liable for just the assessment, Medicare providers must be in compliance with the home health Conditions of Participation (COPs), as follows:
(Medicare Claims Processing Manual)
If a decision is made to hold a beneficiary liable for just the assessment, Medicare providers must be in compliance with the home health Conditions of Participation (COPs), as follows:   42 CFR 484.10.e (1) The patient has the right to be advised, before care is initiated, of the extent to which payment for the HHA services may be expected from Medicare or other sources, and the extent to which payment may be required from the patient.  Be fore care is initiated, the HHA must inform the patient, orally and in writing, of: (i) The extent to which payment may be expected from Medicare, Medicaid or any other Federally funded or aided program known to the HHA; (ii) The charges for services that will not be covered by Medicare; and (iii) The charges that the individual has to pay.  Therefore, while no notice may be required if the provider chooses to be liable, the conditions state a notice is required if the beneficiary is to be held liable, and must be delivered prior to the service in question.  ABNs can be used for this purpose.  2. Billing in Excess of the Benefit.  In some states, the Medicaid program will cover more hours of care in a week than the Medicare benefit.  Therefore, an HHA may be billing hours/visits in excess of the benefit during a Medicare home health period of ca re for a dually eligible beneficiary.  Since the care delivered in excess of the benefit is not part of the benefit, and does not affect the amount of Medicares prospectively set payment, there is no dispute as to liability, and an ABN is not required unl ess a triggering event occurs; that is, care in excess of the benefit is not a triggering event in and of itself requiring an ABN.  Billing services in excess of the benefit is discussed in C in this section.   3. One -Visit Periods.  Since intermittent skilled nursing care is a requirement of the Medicare home health benefit, questions often arise as to the billing of one -visit periods of care.  Medicare claims systems will process such billings, but these billin gs should only be done when some factor potentially justifies the medical necessity of the service relative to the benefit.
(Medicare Claims Processing Manual)
Many of these cases do not even need to be demand billed, because coverage is not in doubt, since physician orders called for delivery of the benefit.  When the beneficiary dies after only one visit is a clear -cut example.  When physician orders called for  additional services, but the beneficiary died before more services could be delivered, the delivery of only one visit is covered.  The death is indicated on the claim with use of patient status code 20.  Other cases in which orders called for additional s ervices, but circumstances prevented delivery of more than one service by the HHA, are also appropriately billed to Medicare in the same fashion.  There may be rare cases where, even though orders do not clearly indicate the need for additional services, the HHA feels delivery of the service is medically justified by Medicares standard, and should be covered.  In such situations, when doubt exists, an HHA should still give the beneficiary an ABN if a triggering event has occurred, explaining Medicare may not cover the service, and then demand bill the service in question.  No billing is required when there is no dispute that the one service called for on the order does not meet the requirements for the Medicare home health benefit, or is not medically necessary.  However, there are options for billing these non- covered servi ces as discussed in chapter 1, section 60 of this manual.  Note the COPs may require notification in this situation if the beneficiary is to be held liable, as discussed in number 1, immediately above.      60 - No Payment Billing (Rev.11341; Issued:04- 07-22; Effective: 10 -01-22; Implementation: 10 -03-22)  Home health agencies may seek denials for entire claims from Medicare in cases where a provider knows all services will not be covered by Medicare.  Such denials are usually sought because of the requirements of other payers for providers to obtain Medicar e denial notices before they will consider providing additional payment.  Such claims are often referred to as no -payment bills or billings for denial notice.
(Medicare Claims Processing Manual)
A. Submission and Processing  In order to submit a no- payment bill to Medicare under HH PPS, providers must use TOB 0320, and condition code 21.  Claims with condition code 21 and any other TOB will be returned to the provider for correction.  A Notice of Admission (TOB 032A) is not required before the submission of a claim with TOB 0320 and condition code 21.  The statement dates on the claim should conform to the billing period they plan to submit to the other payer, insuring that no future date is reported.  Providers must also submit the charge for each line item on the claim as a non -covered charge.   In order for these claims to process through the subsequent HH PPS edits in the system, providers are instructed to submit a 0023 revenue line on the claim.  If no OASIS assessment was done or if the HHA chooses not to perform payment grouping before submi tting the claim, report any valid HIPPS code.  The claim must meet other minimum Medicare requirements.  If an OASIS assessment was done and the HHA chooses to perform payment grouping for their internal accounting purposes, the HHA may report the resulting HIPPS code.    B. Simultaneous Covered and Non- Covered Services   In some cases, providers may need to obtain a Medicare denial notice for non- covered services delivered in the same period as covered services that are part of an HH PPS period of care.  In such cases, the provider should submit a non- payment bill according to the instructions above for the non- covered services alone, AND submit the appropriate NOA and claim for the HH PPS period of care.  The period billed under the HH PPS claim and the non- payment bill should be the same.  Medicare standard systems and the CWF will allow such duplicate claims to process when all services on one claim are non -covered.
(Medicare Claims Processing Manual)
C. Custodial Care under HH PPS, or Termination of the Benefit during a Period  In certain cases, Medicare allows the use of no payment claims in association with an ABN involving custodial care and termination of a benefit during a period of care.  This does not apply to cases in which a determination is being requested as to the beneficiarys homebound status at the beginning of a period of care; there an ABN must be used assuming a triggering event occurs (i.e., the initiation of c ompletely noncovered care).  However, in cases where the HH plan of care prescribes only custodial care, or if the benefit has terminated during a previous period, and the physician, beneficiary, and provider are all in agreement the benefit has terminated  or does not apply, home health agencies (HHAs) can use:   1. The ABN for notification of the beneficiary, and,   2. A condition code 21 no- payment claim to bill all subsequent services.   70 - HH PPS Pricer Program  (Rev. 1, 10- 01-03) HH- 475.4  70.1 - General  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)
(Medicare Claims Processing Manual)
70.1 - General  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Home health services billed on TOB 032x are reimbursed based on calculations made by the HH Pricer.  The HH Pricer is a module within Medicare claims processing systems.  The HH Pricer makes all payment calculations applicable under HH PPS, including claim payments for full periods of care, and all payment adjustments, including low utilization payment adjustments (LUPAs), partial period payment adjustments, and outlier payments.  Medicare claims processing systems send an input record to Pricer for all claims with covered visits, and Pricer will return an output record to the shared systems.  The following sections describe the elements of HH PPS claims that are used in the HH PPS Pricer and the logic that is used to make payment determinations.  No part of the Pricer logic is required to be incorporated into an HHAs billing system in order to bill Medicare.  The following is presented for A/B MACs (HHH) and as information for the HHAs, in order to help HHAs understand their HH PPS payments and how they are determined.   70.2 - Input/Output Record Layout  (Rev. 10919, Issued:08- 06-21, Effective:01 -01-22, Implementation: 01- 03-22)  The required data and format for the HH Pricer input/output record for periods of care beginning on or after January 1, 2021 are shown below:    File Position  Format  Title  Description  1-10 X(10)  NPI Input item:  The National Provider Identifier, copied from the claim form.  11-22 X(12)  HIC Input item:  The Health Insurance Claim number of the beneficiary, copied from the claim form.  23-28 X(6)  PROV -NO Input item:  The six -digit CMS certification number, copied from the claim form.  29 X INIT -PAY -QRP -INDICATOR   Input item: A single character to indicate whether payment should be reduced under the Quality Reporting Program.  Medicare systems move this value from field 18 of the provider specific file. Valid values:  0 = Make normal percentage payment  2 = Make final payment reduced by 2%  30-35 9V9(5)
(Medicare Claims Processing Manual)
PROV -VBP -ADJ-FAC  Input item: Medicare systems move this information from from field 30 of the provider specific file.   36-45 9(8)V99  PROV -OUTL -PAY- TOT  Input item:  The total amount of outlier payments that have been made to this HHA for periods of care ending during the current calendar year.    46-56 9(9)V99  PROV -PAYMENT -TOTAL  Input item: The total amount of HH PPS payments that have been made to this HHA for periods of care ending during the current calendar year.  57-59 X(3)  TOB  Input item:  The type of bill code, copied from the claim form.  60-64 X(5)  CBSA  Input item:  The core based statistical area (CBSA) code, copied from the value code 61 amount on the claim form.  File Position  Format  Title  Description  65-69 X(5)  COUNTY -CODE  Input item: The FIPS State and County Code copied from the value code 85 amount on the claim form.  70-77 X(8)  SERV -FROM -DATE  Input item:  The statement covers period From date, copied from the claim form.  Date format must be CCYYMMDD.  78-85 X(8)  SERV -THRU DATE  Input item:  The statement covers period through date, copied from the claim form.  Date format must be CCYYMMDD.  86-93 X(8)  ADMIT -DATE  Input item:  The admission date, copied from claim form.  Date format must be CCYYMMDD.  94 X LUPA -SRC -ADM  Input Item:  Medicare systems set this indicator to B when condition code 47 is present on the claim.  The indicator is set to 1 in all other cases.  95 X ADJ-IND Input Item:  Medicare systems set the adjustment indicator to 2 when a LUPA add- on claim is identified as not being the first or only period in a sequence.  The indicator is set to 0 in all other cases.  96 X PEP-IND