Frequently Asked Questions
- Q. Will the Medicare claim extend back earlier than May 1, 2022 or later than October 31, 2022? It is possible that the first episode will begin prior to May 1, 2022, or that the final episode will extend beyond October 31, 2022. How the agency established the episode beginning and ending dates will determine this. There are some specific rules for establishing episode dates, but the agency may also have some flexibility in this and may find it easier to align episode dates with already established plans of care. In any event, all services within the episode dates that were billed to Medicaid must be included on the Medicare claim, even if they occurred before May 1, 2022, or after October 31, 2022. PLEASE BE SURE TO SUBMIT CLAIMS FOR THE FULL EPISODES, IN ACCORDANCE WITH THE DATES ON THE PLANS OF CARE.
- Q. What if some or all of the period listed on Form A falls within periods covered by a Medicare HMO plan? As soon as you receive your TPL Project Packet, please review the list of cases included in the packet (Form A) and confirm each beneficiary’s eligibility or Managed Care Plan enrollment through the Medicare Common Working File right away. If a beneficiary was enrolled in a Medicare Advantage Plan at any time during the period March 1 – December 31, 2022, please fill out Form B (included in your Phase 15 packet) and return it, along with a print-out supporting MA enrollment, to the Center to the attention of Corinna Beebe ASAP. Please also notify Corinna Beebe (860-336-4818) of any beneficiaries who have Medicare eligibility issues at any time during the period of the Project. MA enrollment periods and eligibility issues may affect episode dates. Corinna will review the information submitted and will provide further instructions as soon as possible. It is imperative that claims are billed appropriately in these cases, especially if the MA period begins or ends within an episode. If a claim is not submitted correctly, Medicare will dismiss the entire episode, and your agency may be held financially liable.
- Q. What about a patient who has private insurance as primary. How do we proceed? Such situations will be handled on a case-by-case basis. Please refer particular cases to Corinna Beebe at 860-336-4818 or Lisa Moore at 860-336-4815.
- Q. Should we submit claims with a condition code ‘’21’’ asking for a denial? Absolutely not.
- Q. Will providers be compensated for each case that is copied and mailed? No.
- Q. When must a claim be submitted as an “adjusted” bill? If services affected by the Project fall within the dates of claims that were previously established in Medicare’s Common Working File, the existing claim needs to be adjusted to include the additional services. If these additional services can be billed as covered, please do so. If it is still your opinion that the additional services do not meet Medicare coverage criteria, they may be billed as non-covered using Condition Code 20 and the claim should include a dollar amount in the “non covered” column. However it is very important that you do not include the previously paid services in the “non-covered” column or they will very likely be denied and the prior payment will be recouped by Medicare. In all cases, please be sure to properly bill and send to the Center documentation for all visits rendered during the affected episodes, even if they have already been paid by Medicare. If services are included on the bill but not included in the documentation, Medicare will deny the visits, even if they were submitted as “covered” and even if they were previously paid.
- Q. Are Medbox prefill cases billed to Medicare as SN visits? Yes, if this service was performed by a nurse.
- Q. Do we need to bill Medicare for services that were previously billed to Medicaid during the period chosen for the Project? All home health services paid by Medicaid during the episode being submitted should be included on the final claim, even if they were provided before May 1, 2022, or after October 31, 2022. See also the first question, regarding dates earlier than May 1, 2022, and later than October 31, 2022 (above).
- Q. If the beneficiary has only Part B, are Home Health Services covered under Medicare Part B? Yes, beneficiaries are eligible for Home Health Care under both Part A and Part B. Refer to https://www.medicare.gov/coverage/home-health-services for more information. Medicare is aware of a glitch in their system that prevents the submission of an NOA for beneficiaries who are enrolled only in Part B.
- Q. Can claims for this project be submitted to Medicare on paper?
It is our understanding that Medicare claims must be submitted electronically. If you feel your agency may be exempt from this requirement, please contact Medicare Customer Service as noted below.
- Q. Are there any contacts at Medicare for specific billing issues?
Providers may contact Medicare’s Customer Service Line for answers to specific billing questions at the following numbers:
For the Interactive Voice Response System: 866-275-3033
For a Menu prompt to speak with a Representative: 866-289-0423
- Q. How do we deal with claims with rejection code 37253? For questions regarding RTP’d claims for reason code 37253, see: https://www.cms.gov/files/document/se20010.pdf and Correcting Reason Code 37253.
Questions about the state’s operation of the project:
- John Jakubowski, CPA
Director of Quality Assurance
Department of Social Services
Questions about the Center’s operation of the project:
- Lisa Moore, Appeals Administrator
Questions about billing and documentation:
- Corinna Beebe, Appeals Manager
- Lisa Moore, Appeals Administrator
Questions about Medicare coverage and appeals:
- Mary A. Ashkar, Attorney at Law
- Justin F. Lalor, Attorney at Law
CMA Main office: (860) 456-7790
CMA Fax: (860) 456-1704
Mail: P.O. Box 350, Willimantic, CT 06226