Notice of Election: Timely Filing of Hospice Elections

Background

An individual (or his/her authorized representative) must elect hospice care from a Medicare-certified hospice agency to receive the Medicare hospice benefit. If the individual (or authorized representative) elects to receive hospice care, he or she must file a signed election statement with a particular hospice. The start date of the hospice election cannot be prior to the date the election statement is actually signed.

Each hospice designs and prints its own election statement. The election statement must include the following items of information:

• Identification of the particular hospice that will provide care to the individual
• 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
• 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 acknowledgement that the designated attending physician was the individual’s or representative’s choice
• The signature of the individual or representative

Footnotes:

¹ The individual’s or representative’s (as applicable) acknowledgement that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment.

² Hospice care focuses on providing palliative, not curative care. Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.

³ For the duration of an election of hospice care, an individual must waive all rights to Medicare payments for (a) Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice). (b) Any Medicare services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition or that are equivalent to hospice care except for services—(i) Provided by the designated hospice: (ii) Provided by another hospice under arrangements made by the designated hospice; and (iii) Provided by the individual’s attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services.

The hospice then submits a NOE to the MAC, which transmits the information to the CWF. Once the initial election is processed, the CWF maintains the beneficiary in hospice status until death or until an election termination is received.

Upon electing hospice care, the beneficiary waives the right to Medicare payment for any Medicare services related to the terminal illness and related conditions during a hospice election, except when provided by, or under arrangement by, the designated hospice or individual’s attending physician if he/she is not employed by the designated hospice. Prompt filing of the NOE with the Medicare contractor is required to properly enforce this waiver, and prevent inappropriate payments to nonhospice providers.

Timely Filing of the NOE

With the implementation of CR 8877, for claims with dates of service on or after 10/1/2014, timely-filed hospice NOEs must be filed within five calendar days after the hospice admission date. A timely-filed NOE is an NOE that has a receipt date within five calendar days after the hospice admission date and is subsequently processed in status/location P B9997.

• Correcting an Admission Date
  
  As of 1/1/2018, providers will be able to correct an erroneous admission date on a NOE using occurrence code 56 and condition code D0 (zero). A hospice will submit another TOB 8XA, using the correct election date as the ‘From,” admission dates and occurrence code 27 dates. The hospice must also submit the original, incorrect election date on the 8XA using occurrence code 56. Medicare systems use this date to find the election record to be corrected, then replaces the election date with the corrected information. The hospice must also indicate the NOE is a correction by addition condition code D0 (zero). If the occurrence code 56 and condition code D0 are not both present, the NOE will be returned to the hospice.

Correcting Beneficiary Information

• If a NOE is submitted with incorrect beneficiary information (i.e., MBI, last name or DOB), you do not have to wait for the NOE to be returned in status/location T B9997 before submitting a corrected NOE. If the beneficiary’s last name is incorrectly spelled, or the Medicare MBI or DOB is incorrect, a new NOE can be submitted the same day as the incorrect NOE. Note that this will not work if the NOE has correct beneficiary identification information.

Correcting Diagnosis Codes

• If an incorrect diagnosis code is mistakenly entered on the NOE and accepted by the system, providers do not need to/should not cancel and submit a new NOE. A corrected diagnosis would need to be put on the claim.
• If the NOE contains billing errors such as an invalid primary diagnosis, the NOE will not be accepted by CWF or the FISS. When a NOE is corrected out of the RTP file, it will receive a new receipt date. This new date will be used to determine timely submission of the NOE. In this situation, the resubmitted NOE will most likely be outside of the timely filing window for NOEs. An invalid diagnosis on the NOE is a provider billing error and will not meet the requirements for an exceptional circumstance.

Correcting Attending Physician

• If an incorrect attending physician NPI is entered on the NOE, the NOE does not need to/should not be cancelled and resubmitted. The correct attending physician NPI will need to put on the claim.
• If a beneficiary has not selected an attending physician at the time of the NOE submission, it is acceptable to enter the NPI of the hospice medical director. If the beneficiary elects an attending and the physician declines to be the attending physician, and the NOE has already been submitted with the selected attending physician NPI there is no need to cancel or change the NOE. When filing the claim, enter the correct attending physician NPI on the claim. Also, in the event the beneficiary selects another attending physician after the submission of the NOE, you do not need to/should not cancel the NOE. When submitting the claim, put the corrected physician NPI on the claim.

In instances where a NOE is not timely-filed, the days of hospice care from the hospice admission date to the date the NOE is submitted to and subsequently processed by the Medicare contractor will not be covered. The hospice shall report these noncovered days on the claim with an OSC 77, and charges related to the these days shall be reported as noncovered, or the claim will be returned to the provider. The noncovered days will be provider liable, and the beneficiary cannot be billed for them.

The NOE should be submitted within five days of the admission even if the provider believes the NOE will RTP for any reason. When the NOE is entered into the system this will create an audit trail that the NOE was submitted within the five days per the instructions in CR 8877.

Note: If the late NOE also affects the next monthly billing period, the OSC 77 is also required on the subsequent claim and the affected days should be billed as noncovered.

A hospice may request an exception to the timely filing NOE rules which, if approved, waives the consequences of filing a NOE late. The four circumstances that may qualify the hospice for an exception to the consequences of filing the NOE more than five calendar days after the hospice admission date are as follows:

1. Fires, floods, earthquakes or other unusual events that inflict extensive damage to the hospice’s ability to operate
2. An event that produces a data filing problem due to CMS or Medicare contractor systems issue that is beyond the control of the hospice
3. A newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its Medicare contractor or
4. Other circumstances determined by the Medicare contractor or CMS to be beyond the control of the hospice
   • Note: Provider billing errors are in the control of the hospice; therefore, they will not meet the criteria for a valid exceptional circumstance.

Even if a hospice believes that exceptional circumstances beyond its control are the cause of its late-filed NOE, the hospice must still file the associated claim with the OSC 77 to identify the noncovered, provider liable days. The hospice will also report a KX modifier with the site of service code (Q HCPCS codes) associated with the earliest dated level of care line on the claim along with remarks to explain the reason for the late NOE. The KX modifier will prompt us to review the remarks, and if needed, request documentation supporting the request for an exception. If the remarks are sufficient and the exceptional circumstance can be validated based on claims data, an ADR will not be sent to the provider. If an ADR is generated, and documentation supports the exceptional circumstance the claims analyst will process the claim to allow payment.

If the exceptional circumstance cannot be validated as being met either through the remarks and claims data or additional documentation, the claim will be processed as billed. The claim will reject if the NOE was received after the claim dates of service. If the NOE was received within the claim dates of service and the claim is coded appropriately to show this, the claim will process for partial coverage and partial noncoverage. The hospice service code line(s) will be noncovered with reason code 31852 and the other lines will be noncovered with reason code 31947. The only recourse the provider has for a claim that is rejected is to appeal the claim through the normal appeals process. Do not resubmit or adjust a claim that has lines rejected with reason code 31852.

Note: When filing a subsequent claim that contains noncovered days due to a late NOE with an exceptional circumstance, the noncovered days shall be billed with the KX modifier and the OSC 77. In the remarks state, “Late NOE due to and state which of the exceptional circumstances applies,” additional information may be added as necessary to clarify the reason for the subsequent exceptional circumstance.

When adding remarks, please state the following depending on the reason for the late NOE:

1. For fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s ability to operate, please state “Late NOE due to unusual event.”
2. For an event that produces a data filing problem due to a CMS or Medicare contractor systems issue that is beyond the control of the hospice, please state “Late NOE due to data filing problem.”
3. For a newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its Medicare contractor, please state “Late NOE due to newly certified Medicare hospice.”
4. For any other circumstances determined by the Medicare contractor or CMS to be beyond the control of the hospice, please state the reason for the late NOE. If the late NOE is due to sequential billing either with your own facility (e.g., the patient revokes and re-elects the benefit within a few days) or with another facility, please state “Late NOE due to sequential billing.”*

You may add additional remarks to further explain the late NOE, but please start all remarks with the statements above based on your situation. Including detailed additional remarks is recommended

*If you believe the reason for the late NOE is due to sequential billing and we agree, we will approve the request for the exception without requiring additional documentation. If the late NOE is due to any other reason, or the remarks are unclear, a nonmedical ADR may be issued. Please review the ADR narrative for the types of appropriate documentation to submit.

If we approve the request for an exception, we will process the claim with the CWF override code and remove the submitted provider liable days, which will allow payment for the days associated with the late-filed NOE. If we find the documentation does not support allowing an exceptional circumstance, we will process the claim as submitted. The claim will reject and you will have to submit an appeal through the normal appeals process.

Tracking Your Claim

When a claim suspends for an ADR request the claim will show in a status location of SB6000. When an ADR has been issued the claim status location will be SB6001‑ meaning an ADR request has been issued. Providers have fourteen days to submit the requested documentation in response to a non-medical ADR request. When the documentation is received in the claims department, the documentation will be reviewed and the claim will be processed as quickly as possible. The claim if approved will move to a pay status (PB9997). If payment is not allowed the claim will be processed as submitted and will reject to a status location of RB9997. If you do not agree with the decision you must file an appeal. Do not resubmit or adjust the claim.

If the claim suspends to a status location of SB6001 and the claim is not adjudicated by day thirty, the claim will deny and move to a status location of DB9997 with reason code 39721. If documentation was sent, and the claim denied for records not received please contact the customer contact center for assistance. A claim denied for no response to Claims ADR (39721) may not be appealed.

NOE Timeframes/Scenarios

To be timely, the NOE must be submitted and subsequently processed within five calendar days after the hospice admission date. For example, if the admission date is 10/1/20XX, the NOE will have to be received by the FISS DDE by 10/6/20XX and subsequently process (status/location P B9997). To determine if the NOE is timely, the system will look at the receipt date of the NOE as long as the NOE ends up in status/location P B9997. If the NOE is RTP for any reason, then the receipt date of the resubmitted NOE will be used.

If the NOE is untimely, the OSC 77 is required reflecting the dates associated with the untimely NOE, and the revenue lines for the OSC 77 dates must be submitted as noncovered. If a hospice believes they meet the exception requirements for the untimely NOE, they must also append the KX modifier to the level of care lines associated with the untimely NOE.

NOE Examples

• Timely NOE: A patient is admitted to hospice on 10/8/20XX. The NOE is submitted on 10/13/20XX (which is within the timely filing limit), and the NOE ultimately processes on 10/17/20XX.
• Untimely NOE: A patient is admitted to hospice on 10/8/20XX. The NOE is submitted on 10/13/20XX and is RTP on 10/14/20XX due to a billing error. The NOE is resubmitted on 10/17/20XX (which is now outside of the timely filing limit), and the NOE ultimately processes on 10/21/20XX.
  • Special Billing Requirements: The OSC 77 will be reported with the dates of noncoverage due to the late filing of the NOE (10/08/20XX‑10/16/20XX), and the revenue code lines associated with the OSC 77 dates will be reported as noncovered.

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• Untimely NOE with Exception: A patient elects, and is admitted to, hospice on 10/8/20XX. The NOE is submitted on 10/10/20XX and is returned to the provider on 10/12/20XX due to sequential billing because the previous hospice has not finished their billing. The NOE is resubmitted on 10/28/20XX, after the previous hospice finishes their billing, and ultimately processes on 11/1/20XX.
  • Special Billing Requirements: The OSC 77 will be reported with the dates of noncoverage due to the late filing of the NOE (10/8/20XX‑10/27/20XX), and the revenue code lines associated with the OSC 77 dates will be reported as noncovered. In addition, the first level of care revenue line associated with the late NOE will be reported with a KX modifier next to the site of service HCPCS code (location Q code) and remarks will state “Late NOE due to sequential billing.”
    • If we agree with the exception, we will move the charges to covered. If we need additional information, we will issue a nonmedical ADR requesting documentation to support the exception. Documentation requested must be received in fourteen days from the date the ADR was generated. If we ultimately disagree, the claim will process as it was submitted. If you disagree with the decision you must file an appeal for the rejected claim.

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Submitting the NOE in FISS/DDE

Step	Action
1	Log into FISS and access the FISS Main Menu
2	Key 02 in the ENTER MENU SELECTION field
3	< Enter > The Claims and Attachments Entry Menu will be displayed
4	Key 49 in the ENTER MENU SELECTION field
5	< Enter > The INST Claim Entry Menu will be displayed

NOE Claim Page 01

Field	Description/Valid Values
MBI (Required)	Enter the beneficiary’s MBI
TOB(Required)	The system default type of bill for the NOE is “81A” 81A (Freestanding hospice: system generated) 82A (Hospital-based hospice: provider keyed)
OSCAR (System)	The Medicare provider number is system generated.
NPI (Required)	Enter the NPI associated with the OSCAR number.
STMT DATES FROM (Required)	Enter the date of the hospice election in the MMDDYY format.
PATIENT DATA (Required)	Enter the beneficiary’s last name, first name, date of birth (MMDDCCYY), full mailing address, ZIP Code and gender.
ADMIT DATE (Required)	Enter the date of the hospice election in the MMDDYY format. (Note that the ADMIT DATE and the STMT DATES FROM date should match.)
OCC CDS/DATE (Required)	Enter the occurrence code 27 along with the date of certification in the MMDDYY format.
FAC. ZIP (Required)	Enter the facility ZIP Code of the provider.

NOE Claim Page 03

Field	Description/Valid Values
CD (System)	“Z” is system generated. Do not change. NOEs should be submitted with Medicare as the primary payer.
PAYER (System)	“Medicare” is system generated. Do not change. NOEs should be submitted with Medicare as the primary payer.
RI (Required)	Enter the release of information indicator. Valid values are: “Y” to indicate you have a signed statement on file permitting you to release data to other organizations to adjudicate claims. “R” to indicate the release is limited or restricted. “N” to indicate there is no release is on file.
DIAGNOSIS CODES (Required)	Enter the hospice diagnosis code, including all five digits where applicable.
ATTENDING PHYS NPI/LN/FN (Required)	Enter the NPI and the name of the attending physician designated by the patient at the time of election as having the most significant role in the determination and delivery of the patient’s medical care.* * If there is no attending physician, enter the certifying physician in this field.
OTHER PHYS NPI/LN/FN (Situational)	Enter the NPI and name of the hospice physician responsible for certifying/recertifying that the patient is terminally ill if the certifying physician differs from the attending physician. Note: For electronic claims using version 5010 or later, this information is reported in Loop ID 2310F – Referring Provider Name.

Submitting the NOE Hardcopy

The following data elements must be completed by the hospice on CMS-1450 form for the NOE if submitting the NOE via hardcopy claim submission.

UB04 (CMS-1450)

 

Field	Description/Valid Values
FL 01	Enter the provider’s name, city, state, and ZIP Code.
FL 04 TYPE OF BILL	Enter the type of bill for the NOE. Valid values are: 81A (Freestanding hospice) 82A (Hospital-based hospice)
FL 06 STATEMENT COVERS PERIOD- FROM	Enter the date of the hospice election in the MMDDYY format.
FL 08 PATIENT NAME	Enter the beneficiary’s last name and first name in Line A.
FL 09 PATIENT ADDRESS	Enter the beneficiary’s full mailing address, including street number and name, city, state, and ZIP Code.
FL 10 PATIENT BIRTHDATE	Enter the beneficiary’s date of birth in the MMDDYY format.
FL 11 PATIENT SEX	Enter the beneficiary’s gender. Valid values are: “M” (male) “F” (female)
FL 12 ADMISSION DATE	Enter the date of the hospice election in the MMDDYY format. (Note that the ADMISSION DATE and the STATEMENT COVERS PERIOD-FROM date should match.)
FL31 OCCURRENCE CODE/DATE	Enter the occurrence code 27 along with the date of certification in the MMDDYY format.
FL 50 PAYER IDENTIFICATION	Enter “Medicare.” NOEs should be submitted with Medicare as the primary payer.
FL 51 HEALTH PLAN ID	Enter the Medicare provider number (OSCAR number)
FL 52 RELEASE OF INFORMATION CERTIFICATION INDICATOR	Enter the release of information indicator. Valid values are: “Y” to indicate you have a signed statement on file permitting you to release data to other organizations to adjudicate claims. “R” to indicate the release is limited or restricted. “N” to indicate there is no release is on file.
FL 56 NPI	Enter the NPI associated with the OSCAR number.
FL 58 INSURED’S NAME	Enter the beneficiary’s name as shown on the Health Insurance card or other Medicare notice.
FL 60 INSURED’S UNIQUE ID	Enter the beneficiary’s MBI.
FL 67 PRINCIPAL DIAGNOSIS CODE	Enter the hospice diagnosis code, including all five digits where applicable.
FL76 ATTENDING: NPI/LAST/FIRST	Enter the NPI and the name of the attending physician designated by the patient at the time of election as having the most significant role in the determination and delivery of the patient’s medical care.* * If there is no attending physician, enter the certifying physician in this field.
FL 78 OTHER: NPI/LAST/FIRST (Situational)	Enter the NPI and name of the hospice physician responsible for certifying/recertifying that the patient is terminally ill if the certifying physician differs from the attending physician.

 

Related Content

• CR 8877 Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election. This CR rescinds and fully replaces CR 8777
• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims