Service Specific Post-Payment Audits of Home Health LUPA Claims

Please note: Some of the TPE reviews will involve claims that have already been processed (postpayment). The notification letter for postpayment TPE reviews will include a listing of all the claims being selected. TPE reviews that are being done for new claim submissions (prepayment) will include a notification letter followed by separate ADRs for each claim involved.

Prior to this restart of TPE reviews, NGS had been conducting service specific post payment reviews. Providers should continue responding to these service specific postpayment ADR requests that have already been issued. Providers are encouraged to review the Medical Review Focus Areas to learn about what services are being selected, what documentation will be requested, and more details on these service specific post-payment reviews.

Edit Reason Code: 5CLPP/5WLPP
Bill Type = 329
HIPPS code: 3HA1x, 3HB1x, 3HB2x
Dates of Service: 3/1/2020 and after

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Overview

When a claim is randomly selected for review, the provider will receive an ADR letter. We must receive the medical records necessary to support the billed services within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in denial of the billed service. All documentation must be legible and authenticated by an acceptable handwritten or electronic signature. We will issue results upon completion of the post-payment review and offer education as needed.

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Documentation Requirements

Actual clinical note (discharge summary, progress note, plan of care, etc.) for the face-to-face encounter.
Initial (start of care) certification by one certifying physician and the initial plan of care regardless of dates of service billed.
Recertification, also by one physician and plan of care to cover this period billed if subsequent date of service.
HHA generated documentation, including, but not limited to the initial nursing, therapy and OASIS assessments.
If a patient’s sole skilled service need is for skilled oversight of unskilled services, submit the physician’s brief narrative documentation describing the clinical justification of the need for service. This statement can be part of the certification or recertification or as a signed addendum.
All signed physican orders.
Home health discipline notes for all services billed and flowsheets supporting coverage of visits.
Initial therapy PT, OT, SLP) evaluation regardless of dates of service billed.
Therapy documentation, including assessment/re-assessments; re-evaluations.
If there is an ABN on file, please include a copy of the signed and dated ABN of non-coverage to the beneficiary.

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Service Specific Post-Payment Audits of Home Health LUPA Claims

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