- Medicare Hospice Quick Reference Sheet
- Hospice Certifying Physician Medicare Enrollment Information
- Hospice Notice of Election Termination/Revocation
- Hospice Room and Board Denials
- Professional Services During a Patient Hospice Election
- Tips to Facilitate the Change of Ownership Process
- Service Intensity Add-on Payment
- Counting 60-Day Election Periods
- Untimely Filed Notice of Election Circumstance Exception: Medicare Beneficiary Is Granted Retroactive Medicare Entitlement
- Hospice Billing Codes Chart
- Appropriate Use of Occurrence Code 27 and Occurrence Span Code 77
- Avoiding Reason Code U5181: Appropriate Use of Occurrence Code 27/Occurrence Span Code 77
- Hospice Notice of Change of Ownership
- Filing an Electronic Notice of Change of Ownership (TOB 8XE)
- Hospice Change of Ownership
- Filing an Electronic Notice of Cancelation (Type of Bill 8XD)
- Filing an Appeal for Claims Rejected for an Untimely Hospice Notice of Election
- Filing an Electronic Notice of Transfer (Type of Bill 8XC)
- Counting 60-Day Election Periods - Leap Year
- Hospice Site of Service Codes
- Billing Hospice Physician, Nurse Practitioner and Physician Assistant Services (Related To Terminal Diagnosis)
- Correcting Hospice Claims Sequentially to Avoid Reason Code U5181
- Common Working File System Edit F5052 and M5052
- Hospice Visit Reporting
- The Medicare Hospice Benefit: Effects on Other Provider Types
- Counting 90-Day Election Periods - Leap Year
- Reporting Hospice Discharges, Revocations and Transfers
- Filing an Electronic Notice of Termination-Revocation of Election (Type of Bill 8XB)
- Avoiding Reason Code 7C625: Appropriate Use of Remarks on Final Hospice Claims
- Notice of Election: Timely Filing of Hospice Elections
- Hospice Claim Submission Job Aid
- Direct Mailing Notification to Hospice Providers Regarding the Hospice Benefit Component, VBID Model, Participating MAOs
- Counting 90-Day Election Periods
- Hospice Quality Reporting Program
- Filing an Electronic Notice of Election (Type of Bill 8XA)
- Hospice Prescription Drug and Infusion Pump Reporting
- Hospice Caps Job Aid
- Value-Based Insurance Design Model Hospice Benefit Component Overview
- Documentation for Hospice Transfers
- Hospice Billing Instructions for Influenza, Pneumococcal and Hepatitis B Vaccines
- Appropriate Use of Condition Code 85
- How to Correct/Avoid Reason Code U5150
- General Inpatient Check Off List
- Hospice Transfers Job Aid
- Medicare Two Tier Routine Home Care Payment Rate
- Canceling a Hospice Notice of Election
- Hospice Pricer Tool Quick Reference Tool
- How to Bill When the Hospice Face-to-Face is Late from a Previous Benefit Period
- Site of Service Codes for Continuous Home Care and General Inpatient Care Level of Service
- Hospice Payment Rates
- Billing Medicare for a Denial - Condition Code 21
- Reminder on Deleting Revenue Code Line(s) in the Fiscal Intermediary Standard System Direct Data Entry System
Untimely Filed Notice of Election Circumstance Exception: Medicare Beneficiary Is Granted Retroactive Medicare Entitlement
Table of Contents
- Untimely Filed Notice of Election Circumstance Exception: Medicare Beneficiary Is Granted Retroactive Medicare Entitlement
- Exceptional Circumstance for Untimely-Filed NOE
- Medicare Hospice Coverage Requirements
- Documentation Requirements
Untimely Filed Notice of Election Circumstance Exception: Medicare Beneficiary Is Granted Retroactive Medicare Entitlement
As part of the hospice election process under the Medicare hospice benefit, the hospice must file an NOE to inform the Medicare claims processing systems that a beneficiary is under a hospice election. Prompt filing of the hospice NOE with the Medicare contractor is required to properly enforce this waiver and prevent inappropriate payments to nonhospice providers.
As stated in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance, Section 20.2.1.1, timely-filed hospice NOEs shall be filed within five calendar days after the hospice admission date. In instances where a NOE is not timely-filed, Medicare shall not cover and pay for the days of hospice care from the hospice admission date to the date the NOE is submitted to, and accepted by, the Medicare contractor. These days shall be provider liable and the provider shall not bill the beneficiary.
Exceptional Circumstance for Untimely-Filed NOE
There may be some circumstances that may be beyond the control of the hospice where it may not be possible to timely-file the NOE within five calendar days after the effective date of election. Therefore, CMS regulations allow for exceptions. Please refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11 Processing Hospice Claims, Section 20.1.1 for a complete list of exceptional circumstances.
When a Medicare beneficiary is entitled to Medicare they may not be notified of the Medicare entitlement for several months after the effective election date. Therefore, it would be beyond the control of a hospice provider to enter a NOE timely, when the beneficiary is granted retroactive entitlement. NGS will grant an exceptional circumstance for an untimely filing of a NOE when coverage criteria has been met and verified. Claims received with an occurrence code 77 and a KX modifier will be suspended and generate a non-medical ADR. NGS will review the requested information to validate that all coverage requirements and retroactive entitlement have been met.
Medicare Hospice Coverage Requirements
Requirements for coverage under the Medicare hospice benefit are that the individual must be entitled to Medicare Part A and the individual must be certified as being terminally ill, with a life expectancy of six months or less if the illness runs its normal course. An individual who receives retroactive Medicare entitlement is entitled to Medicare hospice services effective on the first day of that entitlement.
A valid election statement must meet the criteria listed in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance, Section 20.2.1 which provides the content of the election statement and a valid certification of terminal illness.
To be a valid election statement the content must include:
- Identification of the particular hospice that will provide care to the individual;
- The individual’s or representative’s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment;
- The individual’s or representative’s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election;
- The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement. An individual may not designate an effective date that is retroactive;
- The individual’s designated attending physician (if any). Information identifying the attending physician recorded on the election statement should provide enough detail so that it is clear which physician or NP was designated as the attending physician.
- The individual’s acknowledgment that the designated attending physician was the individual’s or representative’s choice.
- The signature of the individual or representative.
Note: CMS has determined it would be acceptable for the election statement to contain language that states, “in the event I become eligible for Medicare, I or a representative (as applicable) acknowledge and understands that certain Medicare services are waived by the election.” Upon notification of the beneficiaries retroactive entitlement the provider should obtain a new election form that satisfies all the requirements set forth by CMS for a valid election.
To be a complete, valid written physician certification of terminal illness, the content must include:
- The statement that the individual’s medical prognosis is that their life expectancy is six months or less if the terminal illness runs its normal course;
- Specific clinical findings and other documentation supporting a life expectancy of six months or less;
- The signature(s) of the physician(s), the date signed, and the benefit period dates that the certification or recertification covers
- As of 10/1/2009, the physician’s brief narrative explanation of the clinical findings that supports a life expectancy of six months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms;
- If the narrative is part of the certification or recertification form, then the narrative must be located immediately above the physician’s signature.
- If the narrative exists as an addendum to the certification or recertification form, in addition to the physician’s signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum.
- The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record or, if applicable, his or her examination of the patient. The physician may dictate the narrative.
- The narrative must reflect the patient’s individual clinical circumstances and cannot contain check boxes or standard language used for all patients. The physician must synthesize the patient’s comprehensive medical information in order to compose this brief clinical justification narrative.
- For recertifications on or after 1/1/2011, the narrative associated with the third benefit period recertification and every subsequent recertification must include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of six months or less
- If a written certification cannot be obtained with in two calendar days (that is by the end of the third day), an oral certification must be obtained and documented in the beneficiary’s medical record. Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance, Section 20.1, for complete instructions on obtaining a valid written and oral certification.
Documentation Requirements
Upon receiving a request for an exception to the timely-filed NOE policy for retroactive Medicare entitlement, the MAC must also request and receive supporting documentation that the individual meets eligibility requirements under the Medicare hospice benefit. Specifically, the MAC must request and receive:
- Proof of retroactive Medicare entitlement;
- The certification of terminal illness that meets the criteria set forth in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance Section 20.1; and
- The hospice election statement that meets the criteria set forth in theCMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance Section 20.2.1.
A retroactive Medicare entitlement qualifies as one of the exceptions to a timely-filed NOE as this would be a circumstance that is beyond the hospice’s control. Therefore, if the requesting hospice’s supporting documentation meets the three criteria listed above, NGS will not hold providers liable for those days from the effective date of the retroactive Medicare entitlement to the date of the filing of the NOE and to pay claims from the effective date of the hospice election for which there is entitlement under Medicare.
Tip: When submitting a claim for an untimely NOE that meets the exceptional circumstance be sure to include in your remarks, “Late NOE due to retroactive Medicare entitlement.” Once you have stated the exact nature of why you are requesting an exceptional circumstance you may add any additional comments to assist in further clarifying the circumstance.
Scenarios for Application
- Scenario 1: A patient elected the hospice benefit on 11/13/2015 the election form, assessments, certifications and narratives all meet Medicare hospice requirements. In February the provider/beneficiary was notified that Medicare was effective 11/1/2015.
- In this scenario the beneficiary was eligible for Medicare at the time of the election and therefore retro-active entitlement would apply, as an exceptional circumstance for a late filed NOE.
- Scenario 2: A patient elected hospice on 11/13/2015, the election form, assessments, certifications and narratives all meet Medicare hospice requirements at the time of admission. In February the provider/beneficiary is notified Medicare was effective 12/1/2015.
- In this scenario the initial certification would have to occur on or after 11/15/2015 and no later than 12/1/2015 in order to be a timely physician certification. Therefore retro-active entitlement in this situation would not apply as an exceptional circumstance for a late filed NOE.