For Services Provided From:
May 1, 2012 through October 31, 2012
The individuals identified on the attached list (Form A) were eligible for both the state Medicaid program and the federal Medicare program during the period described above. The home health care services provided to these individuals by your agency during this time period were previously submitted to and paid for by the state Medicaid program. The Connecticut Department of Social Services now requests that your agency submit claims for these home care services to the federal Medicare program, so that your Medicare Administrative Contractor can determine whether some or all of the services can be covered by Medicare.
Please note: It is imperative that you refer to your Medicare billing manual and your Medicare contractor for specific directions about billing and documentation. After reviewing this packet, if you have any questions about the program requirements or any of the enclosed documents, please call the Center for Medicare Advocacy at (800) 262-4045.
SUMMARY OF PROJECT DEADLINES
February 8, 2013…………………… Final date for Center’s receipt of Homebound Assessment Forms. Submit to the Center’s Connecticut Office.
March 8, 2013………………………. Medical Records Due at the Center’s Connecticut Office (NOTE: Please DO NOT Send to Center’s Maine Address) (Or as soon as RAP is submitted, whichever is earlier).
March 15, 2013 ……………………. Results of Homebound Assessments will be sent to the providers.
March 22, 2013…………………….. Submit RAPs to Medicare – Highly recommended date.
March 29, 2013…………………….. Submit Final Claims to Medicare – Highly recommended date.
April 30, 2013……………………….. Submit Final Clean Claims to Medicare CMS Deadline! Claims may not be accepted after this date!
Immediately Upon Receipt……. Fax, ship or securely email ADRs to the Center’s CT OFFICE. Please note there is a 30 day deadline from the date of the ADR in which to submit medical records to Medicare.
Immediately Upon Receipt……. Fax, ship or securely email Medicare Claim Status results to the Center’s CT OFFICE. Please note there is a 120 day deadline from the date of the Medicare Denial in which to file an appeal to Medicare.
Please Visit The Center For Medicare Advocacy Website to View FAQs at:
− INSTRUCTIONS −
CONNECTICUT MEDICARE HOME HEALTH TPL PROJECT
For Services Provided From: May 1, 2012 through October 31, 2012
1. Form A lists those individuals who received services from your agency and for whom Medicare claims are to be submitted. Please review the information on this form to make sure that the individuals’ names, HIC numbers, and Medicaid ID numbers are correct according to your records. If any of these details are incorrect, please contact the Center’s Data Unit immediately at (800) 262-4045.
2. Medicaid Recipients Whose Claims are Identified for
3. Medicaid Claims Identified for
If there are services within the identified episodes that you have previously billed to Medicare and that have already been either paid or denied, then you must submit to the Center copies of relevant documents from Medicare showing the result of your billing.
4. Outline of Project Billing and Records Submission Steps:
The “retrospective” billing to Medicare in this project varies somewhat from “real time” billing. The basic project billing steps are listed here. Details about each of these billing steps are included in the following pages. The steps essential to meeting the requirements of this project are:
a. If there are any cases or episodes for which the documentation clearly demonstrates that the patient was not “homebound” during the period at issue and for which you want the Center to make a pre-appeal evaluation of homebound status, complete the Homebound Assessment Form as described at Section 13, below.
b. For all cases in which Homebound Assessment Forms are not completed or in which the Center’s homebound assessment finds that a Medicare appeal will be pursued, identify episode “from” and “through” dates. Note, these dates may begin before May 1, 2012, and may end after October 31, 2012. (See Section 5)
c. Gather and submit medical records for all services provided during these episode dates to the Center. (See Section 6)
d. Identify the “Date of Admission,” which may be earlier than May 1, 2012. (See Section 7)
e. Determine whether the bill will be a new bill or an adjusted bill. (See Section 8)
f. For new bills, submit Requests for Anticipated Payment (RAPs) to Medicare. (See Section 9)
g. Submit final claims to Medicare. (See Section 10)
h. Submit Additional Development Requests (ADRs) to the Center immediately upon receipt via FTP (preferred) or other method. (See Section 11)
i. Submit Medicare Claim Status results to the Center’s Data Unit immediately upon receipt via FTP (preferred) or other method. (See Section 12)
It is particularly important to properly identify the first set of episode dates correctly. The following episodes will often, although not always, follow in 60-day increments thereafter. Please be sure the claim dates do not overlap periods during which the beneficiary was not eligible for Medicare or enrolled in a Medicare Managed Care Plan. These individuals are not included in this year’s project.
If the patient is not Medicare Part A or Part B eligible for part of an episode, contact NHIC, J-14 Customer Service Line at 866-289-0423 for specific instructions as to how to establish and bill for the related services. Please also notify the Center’s Data Unit of the correct Part A and/or Part B eligibility dates for the patient.
Generally, the first set of episode dates may be identified as follows:
1. Identify the Plan of Care which includes the first service date identified according to the instructions in Section 4.
2. The start date of this Plan of Care may be, but is not always, the start date for the first episode to be billed.
3. The end date for the first episode will generally be sixty days after the start date, although an earlier discharge or some other event may require that an episode shorter than sixty days be billed.
Episodes do not need to match exactly the dates of particular Plans of Care. Medicare requires only that all of the individual services included on the claim be covered by a valid Plan of Care.
The first episode to be billed may begin prior to May 1, 2012. Likewise, the final episode to be billed may end after October 31, 2012. NOTE: Services delivered prior to May 1, 2012 (and provided during an episode of care that ended on or after May 1, 2012) may be included in a billing submitted on or before April 30, 2013 and will be considered timely. The Federal regulations permit this and treat it as a timely billing based on existing Medicare policy. See, 75 Fed. Reg. 73449 (November 29, 2010);
If you have previously billed Medicare for any episode which includes services identified for TPL review, there is already a Medicare episode established in the national Medicare Common Working File (CWF). Since this episode has already been established, it must be taken into consideration when you are outlining episodes to include the remaining services. Dates of newly identified episodes must not overlap dates of these previously established Medicare episodes.
6. Regarding Medical Records:
Medicare may conduct a full medical review in all cases for which bills are submitted under this project. The Center’s attorneys will also need to review the medical record in order to determine whether an appeal of Medicare's decision is appropriate. Therefore, records should be submitted to the Center’s CT OFFICE as soon as the RAPs are filed or by March 8, 2013, whichever date is earlier. REMINDER: FAILURE TO MEET PROJECT DEADLINES SHALL RESULT IN FINANCIAL LIABILITY TO YOUR AGENCY.
Please note: If you have already submitted the complete medical record to the Center as part of the Homebound Assessment process, it is not necessary for you to re-submit the medical records to the Center. (See Section 13)
The records to be submitted to the Center are those which are required by Medicare to support the submission of a valid bill. These would include, but not be limited to, the following records for all services provided within each episode of care:
- Home Health Certification and Plan of Care
- Interim doctors' orders and progress notes (valid verbal orders)
- Skilled Nursing notes and flow sheets
- Therapy notes, including initial evaluation and discharge summary
- Home Health Aide documentation
- Social Worker documentation
- Finite and predictable end point to daily care (if applicable)
- OASIS forms corresponding to each episode of care
- Medicare Home Health Advanced Beneficiary Notices (HHABNs) issued
Remember to include documentation for all services provided within the Medicare episode, even if some of the services have previously been paid by Medicare, and even if they were provided before May 1, 2012, or after October 31, 2012.
Records may be submitted to the Center electronically to the Center’s FTP site (preferred) or other method. For further information about these options, see Section 14.
7. Regarding the Date of Admission:
Although each set of circumstances is different, the Date of Admission to be stated on the RAP is quite likely to have occurred at some point prior to May 1, 2012. For Medicare billing purposes, the Date of Admission should be the most recent admission date preceding the service dates billed on the related claim.
If you have previously billed Medicare for services provided to this patient, and if the patient has remained under the care of the agency throughout the period in question, then the Date of Admission may be the same as that identified on the most recent prior Medicare bill.
If the Date of Admission is prior to the start date of the first episode to be billed for this patient, then the bill may be submitted to Medicare as “continuing care” (Patient Status Code 30), even if you have not billed Medicare for earlier services for the patient in question.
As long as the Date of Admission is prior to the start date of the episode being billed, it is not necessary that a billable service occur on the first day of the episode. However, if the Date of Admission is the same date as the first date in the episode being billed, then it is necessary to have a billable “skilled” service occurring on that same date, otherwise the claim will not be accepted by Medicare.
Note: A frequent cause of billing errors for retrospective TPL RAPs and claims is a result of improper identification of the Date of Admission on the Medicare billing forms. FAILURE TO MEET PROJECT DEADLINES SHALL RESULT IN FINANCIAL LIABILITY TO YOUR AGENCY.
8. Regarding the Need for New versus Adjusted Bills:
“Adjustments” are required when any portion of an episode has been previously billed to Medicare. If you have previously billed Medicare for services occurring during any of the periods identified for TPL review, you should not create new episodes and submit new RAPs and claims for those periods previously billed. Instead, you should “adjust” the claims which you have previously submitted for the dates in question. Please refer to your Medicare provider manual for more detailed instructions on submitting adjusted claims.
Except for “adjusted” bills as described above, you must submit RAPs to Medicare for all episodes as necessary to include all of the services identified for TPL review. Except for Condition Codes, the information on the RAP must be consistent with the information on the final claim. (Condition Codes are not to be included on the RAP, but only on the final claim.) For this reason, you should read the instructions relating to final claims (see Section 10 below) as well as the instructions relating to RAPs before submitting the RAPs themselves. If a final claim is not accepted by Medicare because it contains information which is not consistent with the original RAP, then the original RAP may need to be canceled, a new RAP submitted, and the final claim (now consistent with the RAP) resubmitted. The process of correcting and resubmitting RAPs and claims will cause delays, which might jeopardize your ability to get your final claims filed timely. Therefore, it is crucial that accurate PPS episodes be identified when RAPs are submitted.
Please remember, RAPs are not permitted for “adjusted” bills.
The RAP must never include a Condition Code. Condition Code 20 should appear only on the final claim, when required.
RAPs submitted under this Project will be paid by Medicare. However, depending on the ultimate status of the final claim and subsequent appeals, the Medicare payment resulting from the RAP may or may not be recovered by Medicare either when the final claim is submitted or on a subsequent Remittance Advice.
The RAP must be successfully submitted to Medicare before you submit the final claim. FAILURE TO MEET PROJECT DEADLINES SHALL RESULT IN FINANCIAL LIABILITY.
10. Regarding Final Claims Submission:
After the RAP has been successfully submitted to Medicare you must submit a final claim within 60 days of the RAP payment. (See Attachment 2; section B – Timeliness of Billing). Accurate final claims must be submitted to Medicare according to project deadlines. Claims must include all services identified for TPL review, as well as any additional home health services provided by your agency that may fall within the episode dates.
If your review of the medical record finds that the services in question are coverable by Medicare, the final claims may be submitted as covered claims. In other cases, the claims must be submitted as “demand” or “patient driven” using Condition Code 20. (Note that the Condition Code is to appear on the final claim, but not on the RAP.) According to Medicare’s instructions at Section 50, Paragraph C, of the on-line Home Health Agency billing manual (Attachment 1) a “demand” claim may include both covered and non-covered charges as long as the covered and non-covered charges are shown in the proper columns on the Medicare claim form.
The information on the final claim must be consistent with the information on the RAP. If a final claim is not accepted by Medicare because it contains information which is not consistent with the RAP, the RAP and/or final claim will need to be canceled or corrected and resubmitted. In order to avoid such problems, it is particularly important that accurate dates of admission and
11. Regarding Additional Development Requests (ADRs):
You must notify the Center’s Data Unit of any Medicare request for medical records until you have received an accurate final claim status. Please submit to the Center, via FTP (preferred) or other method, all ADRs immediately upon receipt to the Center. ADRs are time sensitive and must be received at the Center so that records can be forwarded to Medicare within the given time frame. The Center will retain the medical record you send us and will forward a copy to Medicare.
If Medicare requests records in addition to those already provided to the Center at the time of the RAP submission, please submit the additional records to the Center and inform the Center’s Data Unit. The Center will need to submit these additional records to Medicare as well.
FAILURE TO MEET PROJECT DEADLINES SHALL RESULT IN FINANCIAL LIABILITY TO YOUR AGENCY.
12. Regarding Notification of Results:
Providers must forward copies of their Medicare claim status payment and/or denial notices resulting from this billing to the Center immediately upon receipt. This information is time sensitive and establishes appeal periods that affect both the agency and the state Medicaid program. It is important to note that the deadline for submitting a Medicare appeal is 120 days from the date of the denial, if claims are submitted to the Center after the 120 day appeals deadline, your agency shall be held financially liable for failing to comply with the requirements of the project.
Claim status notices should be submitted via FTP (preferred) or other method to the Center as soon as received by your Agency. Additional information about submitting information to the Center may be found at Section 14 below.
13. Homebound Assessments:
If you believe that the patient does not meet Medicare’s “homebound” requirement during one or more of the episodes identified for appeal, you may submit a Homebound Assessment Form to the Center, and the Center will conduct an independent review of the related facts and documentation in the case. Note: The Center’s review will be based on the Medicare standards and may or may not agree with the provider’s understanding of the case. See Medicare’s homebound standard described in the United States Code (USC) at 42 USC §1395f(a)(2)(C) (p. 3 of Attachment 4-A).
If the Center’s review finds that the patient did not meet Medicare’s homebound requirement, you will receive a notification that the episode(s) in question will be withdrawn from the appeal and need not be billed to Medicare for review.
However, if the Center’s review finds that the patient met Medicare’s homebound requirement or that the documentation provided by the agency is insufficient or equivocal with regard to the patient’s homebound status, you will receive a notification that the episode(s) in question must be billed to Medicare for review.
Because of the time required to conduct the Homebound Assessment and the remaining time which may be needed to submit documentation, RAPS and final bills for cases which must still be billed to Medicare, the Center will not accept Homebound Assessment Forms after February 8, 2013.
One blank Homebound Assessment Form is enclosed in this packet (Attachment 4-A). Please make copies as needed and complete a form for each case you want reviewed. Submit completed Homebound Assessment Forms and the entire medical records to the Center’s CT office via FTP (preferred) or other method. If you are unable use FTP, you may send a CD or paper records to the Center at 11 Ledgebrook Drive in Mansfield, CT 06250. Specific shipping instructions for submitting HBA cases can be found in Attachment #5. Please call the Center at (860) 456-7790 or (800) 809-6485. for instructions for submitting records to our FTP server.
In addition, please complete the Homebound Assessment Records Tracking Sheet (See Attachment 4-B). Submit to the Center via FTP (preferred) or other method. The information on this form will assure that your Homebound Assessment cases and related records will be properly tracked and accounted for within the Project.
Results of the Center’s Homebound Assessments will be sent to providers by March 15, 2013. Any client case in which the Center finds the patient is “homebound” according to the legal standards or in which the Center finds the patient’s homebound status is equivocal must be billed to Medicare for review. If the Center’s response to a case submitted for Homebound Assessment is not received by the provider by March 15, 2013, please contact us immediately to determine the status of the case. Remember: If you do not receive the Center’s written acknowledgement that a Homebound Assessment case is to be closed and removed from the project, you must submit the related claims to Medicare for review according to the project deadlines. FAILURE TO MEET PROJECT DEADLINES SHALL RESULT IN FINANCIAL LIABILITY TO YOUR AGENCY.
14. Delivery Instructions:
The preferred method of delivery of all documents is electronically through the Center’s FTP site. See Instructions on Attachment 3 and the Center’s FAQ page:
a. Scanned records and CMS responses:
1. Please use PDF format.
2. Each patient’s complete record must be included in a single electronic file. Please upload files to our FTP site. If it is necessary to use a CD or flash drive (“CD”), more than one file may be included on a single CD.
3. See below for instructions on how to name the file (Section 15)
4. Transmit to the Center via either FTP (preferred), secure email or CD. (See below)
5. If the files are password protected, please use the following password: ct2013
Via FTP: The preferred method of transfer is through FTP, which is a secure link between your computer and the Center’s computer system. Contact Lisa Hall at the Center: (860) 456-7790 or (800) 809-6485. or email@example.com with questions about FTP transfer instructions.
On CD: More than one patient’s PDF file may be included on one CD. Ship CDs by mail or by a delivery service to the Center’s CT OFFICE at the address noted in Section 15. Retain shipping records so that you can verify delivery. (See specific shipping instructions and address information for submitting Routine CDs or Medical Records on Attachment #6-A).
- If your Agency needs to send Large Volume Paper Records:
1. Please do not use staples, post-it notes or paper clips on these records.
2. Oversize records should be reduced to 8 ½ x 11, if possible.
3. Please send either all single-sided or all double-sided records only. (Please do not combine these two formats.)
4. Please use elastics to separate individual patient records.
- Shorter and Time Sensitive Paper Records:
1. Time-sensitive Additional Development Requests (ADRs-which have a 30 day deadline for submitting medical records), and
2. Time-sensitive Final Claim Status results (which have a 120 day deadline for filing an appeal to Medicare) should be submitted via FTP (preferred) or other delivery method to the Center as soon as they are issued.
d. ADRs and Final Claim Status results can usually be retrieved as “print-screens” from your computer as follows:
1. Locate the relevant page in the FISS system;
2. Press the “Print Screen/SysRq” key on the upper, right-hand side of your keyboard;
3. Open up your word processing program, then:
4. Click your clipboard icon or right mouse button and paste the captured screen image into your word processing document;
5. Submit as an attachment to the FTP site. If necessary, print the document for faxing or ship to the Center.
Reminders: Remember to include documentation for all services provided within the Medicare episode, even if some of the services begin before May 1, 2012, end after October 31, 2012, or have previously been paid by Medicare.
Whatever method you use to submit your documents, please retain the confirmation information for your records.
15. Instructions for Naming Electronic Files:
Please use the following file naming convention for electronic records:
Per Medicare’s request please avoid using punctuation marks in electronic file names.
Patient CMA case # (found on your client listing-Form A) (space) last name (space) first name (space) HIC# (space) Medicare “OSCAR” number. For example, for records for CMA case #11-123456 Mary Smith, HIC# 123-99-4567A from the provider with Medicare OSCAR number 077123, use: 12-123456 Smith Mary 123994567A 077123 (if you are sending electronic records to the Center for Homebound Assessment (HBA) review, please include “HBA” at the end of the filename after the Medicare OSCAR number (e.g. 12-123456 Smith Mary 123994567A 077123 HBA) and be sure to include the completed Homebound Assessment form as the first page of the PDF file.).
If you plan to password protect files, please use the password ct2013 (lower case “ct” followed by the numbers “2013”). If you must use a different password, it is extremely important that you communicate this to the Center.
Send via FTP site (preferred) or
Center for Medicare Advocacy, Inc.
11 Ledgebrook Drive
Mansfield, CT 06250
Questions? Call the Center at (860) 456-7790 or (800) 809-6485.
REMINDER – CT Home Health TPL Project Deadlines
February 8, 2013…………………………….. Final date for Center’s receipt of Homebound Assessment Forms. Send to the Center’s CT Office.
March 8, 2013………………………………… Medical Records Due at the Center’s CT OFFICE (Or as soon as RAP is submitted, whichever is earlier)
March 15, 2013………………………………. Results of Homebound Assessments will be sent to the providers
March 22, 2013………………………………. Submit RAPs to Medicare – Highly recommended date
March 29, 2013………………………………. Submit Final Claims to Medicare – Highly recommended date
April 30, 2013…………………………………. Submit Final Clean Claims to Medicare – CMS Deadline! Claim may not be accepted after this date!
Immediately Upon Receipt……………FTP or securely email ADRs to the Center’s CT OFFICE. Please note there is a 30 day deadline from the date of the ADR in which to submit medical records to Medicare.
Immediately Upon Receipt……………FTP or securely email Medicare Claim Status results to the Center’s CT OFFICE. Please note there is a 120 day deadline from the date of the Medicare Denial in which to file an appeal to Medicare.
FAILURE TO MEET PROJECT DEADLINES SHALL RESULT IN FINANCIAL LIABILITY TO YOUR AGENCY!
Please refer to the Center’s Website for Frequently Asked Questions (FAQs) at: