National Association for Home Care & Hospice How to Stay Informed: Updates from Palmetto GBA Part I Presented by Charles Canaan Top Reasons for HH Denials 1 56900 Auto Denial - Requested Records not Submitted 2 5F023 No Plan of Care or Certification 3 5FF2F Face to Face Encounter Requirements Not Met 4 5FT10 Documentation Does Not Support Homebound Status 5 5FNOA Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate Oasis Not Submitted 6 5CHG3 MR HIPPS Code Change Due to Partial Denial of Therapy Absence of short and/or long term goals within the initial (PT/OT/ST as 7 5T080 appropriate) therapy evaluation documentation 8 5CHG1 MR HIPPS Code Change/Doc Contradicts MO Item(s) 9 5F012 Physician's Plan of Care and/or Certification Present - Signed but Not Dated 10 5F041 Info Provided Does Not Support the M/N for This Service October 2016 2 1
Auto Deny - Requested Records Not Submitted Medical records were not received in response to an Additional Documentation Request (ADR) in the required time frame Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted Aim to submit medical records within 30 days of the ADR date The claim will auto deny on day 46 Submit medical records as soon as the ADR is received October 2016 3 Responding by Mail Attach a copy of the ADR request to each individual claim If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost Do not mail packages C.O.D. Return the medical records to the address on the ADR Be sure to include the appropriate mail code October 2016 4 2
Responding to Request Fax Back of page Margins Clean copy Colored pages CD Each record as an individual image Password October 2016 5 No Plan of Care or Certification The services billed were not covered because the documentation submitted did not include the physician s signed certification or recertification October 2016 6 3
No Plan of Care or Certification Include plan of care for current episode Verbal orders signed before claim is billed Include initial plan of care for subsequent episodes Send legible copy October 2016 7 Recertification Requirements Must be signed and dated by the physician who reviews the plan of care. Indicate the continuing need for skilled services. Estimate how much longer the skilled services will be required. October 2016 8 4
Face to Face Encounter Requirements Not Met Include face to face encounter note with each request October 2016 9 Wait a Minute!!!!! I submitted a face to face encounter but my denial said face to face not submitted!!! October 2016 10 5
What is an Encounter? Based on examples from MLN SE 1405, an encounter includes information such as: Chief complaint History of present illness Physical exam Assessment Plan October 2016 11 Additional Information Information from the HHA can be incorporated into the certifying physician s and/or the acute/post-acute care facility s medical record for the patient Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered The certifying physician must review and sign off on anything incorporated into the patient s medical record that is used to support the certification of patient eligibility October 2016 12 6
Additional Information This could include, but is not limited to: Comprehensive assessment Inpatient discharge summary Multi-disciplinary clinical notes Must correspond to the dates of service being billed October 2016 13 Documentation Does Not Support Homebound Status The services billed were not covered because the medical records submitted for review did not support homebound status Documentation must indicate and support the beneficiary is unable to leave home A beneficiary is considered to be homebound if there exists a condition due to illness or injury that restricts the ability to leave the place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person or if leaving home is medically contraindicated October 2016 14 7
Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate OASIS Not Submitted The services billed were not covered because the home health agency did not submit the OASIS for the HIPPS code billed on the claim To avoid denials for this reason, the provider should ensure that the OASIS that generated the HIPPS code for the claim is submitted with the medical records in response to an ADR October 2016 15 Partial Denial for Therapy Resulting in Medical Review HIPPS Code Change The services billed were paid at a lower payment level. Based on medical review, the original HIPPS code was changed In order to receive a higher level of payment based on therapy services, there should be an adequate number of payable therapy visits to meet the threshold. This may include one type of therapy or a combination of occupational, speech-language pathology, or physical therapy services Based on the medical records submitted for review, some of the therapy visits were not allowed and reimbursement was adjusted due to a partial denial October 2016 16 8
Absence of Short and/or Long Term Goals within the Initial (PT/OT/ST as Appropriate) Therapy Evaluation Documentation 1. Who 2. Will do what 3. Under what conditions 4. How well 5. By when October 2016 17 Medical Review HIPPS Code Change/Documentation Contradicts M Item(s) The services billed were paid at a different payment level. Based on medical review, the original HIPPS code was changed. To avoid changes for this reason, the documentation should paint a consistent picture of the patient s condition The medical documentation submitted contradicted your response to one or more of the OASIS items. As a result, reimbursement has been adjusted. October 2016 18 9
Physician s Plan of Care and/or Certification Present Signed but Not Dated The service(s) billed (was/were) not covered because the physician signed but did not date the plan of care and certification prior to billing Medicare In order to avoid unnecessary denials for this reason, the provider should verify that the physician has dated his/her signature Pay attention to the margins October 2016 19 Info Provided Does Not Support the M/N for This Service Acute vs Chronic Why does the person need service now? Why is the person continuing on service? October 2016 20 10
How to Stay Informed: Updates from Palmetto GBA Part II Presented by Dan George October 2016 21 Provider Enrollment Revalidation MLN Matters Number: SE1605 Requires all providers/suppliers to resubmit and recertify the accuracy of enrollment information DME suppliers are required to revalidate every 3 years; all other providers/suppliers every 5 years All providers/suppliers must be revalidated under the new enrollment screening criteria October 2016 22 11
Provider Enrollment Revalidation Due Dates CMS has established dates by which providers/suppliers must revalidate To make it easier, when a provider is asked to revalidate, the due date assigned will always be on the last day of the month specified (e.g. June 30, July 31, August 30) With subsequent revalidation cycles, provider s due dates will generally remain the same October 2016 23 Due Dates (Continued) To assist providers, the CMS developed a Lookup Tool. It will display: all currently enrolled providers/suppliers A due date or an indication of a TBD in the due date field. TBD: To Be Determined (more than 6 months until your due date) Due dates will be posted up to 6 months before revalidation due date and are updated periodically https://data.cms.gov/revalidation October 2016 24 12
Revalidation Letters Palmetto GBA will issue revalidations letters within 2-3 months of a given provider s established due date Notices will be sent one of two methods: eservices for providers currently enrolled in Palmetto GBA s self-service portal; or Standard mail October 2016 25 Reminders Each provider/supplier is required to revalidate their entire Medicare enrollment record Failure to take necessary actions to complete revalidation when requested, could result in a hold on your Medicare payments and possible deactivation of your Medicare billing privileges Providers/suppliers deactivated will be required to submit a new full and complete application in order to reestablish their provider enrollment record and related Medicare billing privileges October 2016 26 13
Hospice 2016 October 2016 27 eservices Palmetto GBA s goal is to give the provider secure and fast access to their Medicare information seamlessly via our website through the eservices application. Palmetto GBA s eservices is a free Internet-based, provider self-service secure application. October 2016 28 14
eservices Key Points No cost for registering and using eservices. You can participate in eservices if you have a signed electronic data interchange (EDI) Enrollment Agreement on file with Palmetto GBA. The person who registers is the provider administrator. They grant access for additional users to access, view and print from eservices the information related to registered provider. October 2016 29 eservices Functions Eligibility Claims Status Remittances Online Financial Information payment floor and last three checks paid Financial Forms eoffset requests, echeck payments and CMS-838 Credit Balance form (Part A and HHH only) Secure Forms Appeals, Cost Report Form (Part A and HHH only), Medical Review ADR Response Form, and General Inquiry form Pre-Claim Review - Send PCR requests via the portal October 2016 30 15
eservices Administrator The provider administrator s responsibilities include the following: Creating provider users Any access granted and maintained by the provider administrator is the sole responsibility of that provider administrator. Assigning a temporary password and application permissions to the provider user Modifying the provider user profile Create additional provider administrators October 2016 31 Eligibility The eservices eligibility functions are based on CMS HIPAA Eligibility Transaction System (HETS). When you choose the Eligibility tab, you will see a new set of tabs to display information related to your inquiry. Inquiry Eligibility Deductibles/Caps Preventive Plan Coverage MSP Hospice/Home Health Inpatient October 2016 32 16
Eligibility October 2016 33 Claim Services Enter a Health Insurance Claim Number (HICN) and the date range of date of service for the claims you seek. The claims status date range will default to 45 days from the beginning date. If claims are found for the date range entered, you will receive a list of claims found. Each claim line will have a link to the claims details. Retrieving claims information older than six months may take additional time. October 2016 34 17
Remittance Advices Remittance Advices are available in eservice. Paper Remittance Advices are turned off approximately 30 days after you register. Remittance Advices are available for approximately one year. No limit on number of copies printed. October 2016 35 Financial Tools eoffset requests, echeck payments and CMS-838 Credit Balance form (Part A and HHH only). Open the Financial Tools tab to inquire about your agencies payment floor status and last three checks paid. When you first access the screen, there will be no information. October 2016 36 18
Financial Tools: echeck This function allows payments to be sent electronically to Palmetto GBA. Only check payments are accepted through this form. echeck utilizes technology to make the payment with your financial institution. There is no transaction fee for submitting a check payment. October 2016 37 Financial Tools: eoffset This function allows offset information to be sent electronically to Palmetto GBA. Users have the option to request an immediate offset when they receive a demanded overpayment or make a permanent request for all future demanded overpayments. The form will pre-populate the Contract/Region, Provider Number (PTAN) and National Provider Identifier (NPI) fields with the data associated with the user ID that is logged in. October 2016 38 19
Secure Messaging and Secure Forms eservices users have the ability to submit appeals forms and Medical Review ADR Response form along with attachments, through eservices. If you are an eservices user, you have the advantage or submitting medical records via our free eservices. This will eliminate mailing time and costs! You will also receive a confirmation receipt letting you know when the records are received. October 2016 39 Secure Messaging and Secure Forms Once a form has been accepted into our processing system, the received date will be assigned and an additional message will be generated with the Document Control Number (DCN). Users may currently submit attachments up to 40 MB in size. While there is no limit to the number for files that can be attached to the form, the combined size of all attachments cannot exceed 150 MB in size. October 2016 40 20
Secure Forms October 2016 41 Pre-Claim Review It is the easiest way to submit a PCR request It is the surest way to know it has been received It is the fastest way to receive the decision Validates beneficiary information. This function performs a real-time lookup. The beneficiary must be validated before you may continue. Requests may be saved to be completed at another time October 2016 42 21
eservices References Access Palmetto GBA's eservices eservices FAQs eservices Tips eservices User Manual October 2016 43 Provider Resources October 2016 44 22
Stay Connected to Palmetto GBA Sign up for our listserv Receive daily or weekly email updates via our listserv to stay up-to-date with Medicare and Palmetto GBA news. Subscribe to our RSS Feed When you subscribe to a feed, it is added to the Common Feed List. Updated information from the feed is automatically downloaded to your computer and can be viewed in Internet Explorer and other programs. Find us on Facebook Ask simple/general questions via our Facebook page and receive a response within 24 hours. Follow us on Twitter Follow us on Twitter to view and post short messages. October 2016 45 Other Ways to Stay Connected to Palmetto GBA Contact us Email Ask a question via email using the contact us feature Please do not send questions with Protected Health Information (PHI) YouTube View educational videos on YouTube LinkedIn Stay up-to-date with company news Discover new job opportunities See how you re connected to employees October 2016 46 23
Key Self-Service Tools Claims Payment Issues Log Look here for issues affecting claims payment. Sign up to receive email updates for specific issues. Hospice Rate Calculator Provides rates for the two RHC payment levels Service Intensity Add-on rate Claims Submission Error Help The CSE Help tool may assist you in your compliance efforts by providing information about how to resolve incorrect denials and avoid rejections October 2016 47 Self-Paced Learning Hospice Basics Training Modules These modules provide an overview of hospice eligibility, Notice of Elections (NOEs), claim submission and much more. Home Health Basics Training Modules These training modules provide an overview of home health eligibility verification, requests for anticipated payments (RAPs) and final claim submission Direct Data Entry (DDE) Training Modules These self-paced training modules provide an overview of DDE and are designed to give you the information you need to know to become a proficient DDE user. October 2016 48 24
How to Stay Informed: Palmetto GBA Electronic Data Interchange (EDI) Update Part III Presented by Kim Campbell Website Locating EDI October 2016 50 25
EDI Subtopics October 2016 51 Change to the EDI Enrollment Process October 2016 52 26
Updates to Manuals October 2016 53 Changes to GPNet Additional enhancements for security and speed Changed file names Affected both submitting files and receiving Working with the NSVs to transition submitters Watch for notification from your NSV Complete transition by October 15, 2016 October 2016 54 27
Connectivity Enhancement Subtopic October 2016 55 Direct Data Entry(DDE) Updated DDE Training Modules & Manual Availability changed on July 1, 2016 one less hour DDE IDs are assigned to an individual IDs must be used every 30 days to remain active IDs cannot be shared or transferred with anyone If someone leaves your company, notify us to delete the DDE ID and access October 2016 56 28
DDE IDs Security Team at Palmetto sends out emails to DDE ID users/edi Contacts if a sign on violation is detected Respond to the emails or ID will be deleted Sharing violations average 1-2 calls a day Non-usage violations 3-4 a day October 2016 57 Contact Information Updates Please call us if the following changes: Provider Address Submitter Address EDI Contact Person Name Telephone/Fax Numbers Email Address Please keep your EDI contact information current October 2016 58 29
Calling for Error Assistance When calling for assistance with errors on your 999 or 277CA Reports, please have the following information: Submitter ID Transmission date File ID(ISA13) PTAN/NPI Complete error message October 2016 59 Error Example on a 277CA Report STC*A8:562:85**U*50******A8:128:85~ For a listing of all edits, please go to EDI/Technical Specifications/Medicare Fee for Service CEM Edits STC*A3>23>41**U*********SMARTEDIT: PER CCI GUIDELINES PROCEDURE CODE 99213 HAS AN UNBUNDLE RELATIONSHIP WITH PROCEDURE CODE 90471 BILLED FOR THE SAME DATE OF SERVICE. REVIEW DOCUMENTATION TO DETERMINE IF A MODIFIER OVERRIDE IS APPROPRIATE.~ NOTE: If using a clearinghouse/ billing service, please verify that you are receiving the complete edit message October 2016 60 30
CEM Related Issues EDI System Status and Log will provide information concerning any front end issues including: CEM edits 999 and 277CA Reports 835(ERA) Files October 2016 61 EDI System Status October 2016 62 31
Contact Information EDI Helpdesk hours: 8:00 5:00 ET Telephone number: 1-855-696-0705, please listen carefully to the options and have your PTAN, NPI and Submitter ID available Email address for basic questions: Medicare.edi@Palmettogba.com Fax Number: Part A: 803-699-2429 October 2016 63 32