Situation Report | September 20, 2021
The state Office of the Medicaid Inspector General (OMIG) has resumed its semi-annual demand-billing process for the first half of Federal Fiscal Year (FFY) 2021 as part of the Third Party Liability (TPL) appeals initiative.
Importantly, HCA has also learned additional information from New York’s home health Medicare Administrative Contractor (MAC) — National Government Services (NGS) — about the upcoming process of submitting TPL Demand Bills to NGS involving claims with dates of service in 2021, using the No-Pay Request for Anticipated Payment (RAP) and prospectively in 2022, using the new Notice of Admission (MOA) process.
Below is a summary of the current TPL procedure followed by what’s expected for future appeals targeting claim periods involving no-pay RAPs in Calendar Year (CY) 2021 and NOA’s in CY 2022 and HCA efforts to minimize any new administrative burden.
Current Semiannual Appeals Request
Most Medicare-certified home care providers should have received a letter (dated September 9, 2021) from the state OMIG and its TPL contractor from the University of Massachusetts Medical School (UMMS), identifying which cases have been selected to undergo the current round of appeals (through demand billing). The dates of service span the first and second quarters of FFY 2021 only (October 1, 2020 through March 31, 2021) or the end of the episodic period billed to Medicaid.
UMMS’s letter also says providers should continue monitoring the status of their demand bill claim(s) once submitted. Providers are required to correct any claims that are rejected or suspended by the NGS. In addition, providers are required to timely submit a complete medical record to NGS once the Additional Development Request (ADR) is issued.
A final remittance advice for each episode billed (by demand bill) will be issued within 60 days of the final bill submission to Medicare. Upon receipt of the final remittance advice, providers must send copies of the following documents to UMMS within 10 business days:
- The original claim submitted to the MAC for each 60-day episode billed.
- The final claim remittance advice sent to you from the MAC.
- Each medical record your agency submitted to the MAC upon the ADR request.
Under Medicare requirements, all claims for services must be filed within one calendar year (12 months) after the date of service. In order to comply with this requirement, all demand bills must be submitted within one calendar year from the end date of the certification period identified in the OMIG’s case selection report included with your letter.
HCA members interested in knowing whether they should have received a letter from OMIG can e-mail HCA.
TPL Demand Bills Involving Dates of Service in 2020 (October 1 – December 31, 2020)
For TPL cases selected with dates of services from October 1, 2020 through December 31, 2020), HCA Certified Home Health Agency (CHHA) members can begin the TPL Demand Billing process like it has always been done and submit the regular home health RAP, then final TPL demand bill.
TPL Demand Bills Involving Dates of Service in 2021 (January 1 – March 31, 2021)
As announced last week in the August Medicaid Update, effective immediately, all CHHAs must submit No-Pay RAPs to Medicare for all services rendered to dual-eligible, Medicare/Medicaid recipients, even in cases where the CHHA does not believe the dual-eligible beneficiary meets the Medicare home health criteria and plans to bill Medicaid.
However, since this official guidance from the state did not come out September 9, 2021, for TPL cases selected with dates of services from January 1, 2021 through March 31, 2021, and for CHHAs that did not submit the No-Pay RAP to Medicare in compliance with the 5-day submission requirement (from state of care), NGS is allowing CHHAs to take the following three important steps:
- Submit a No-Pay RAP to CMS for all identified dates of service;
- File a TPL Demand Bill final claim with a KX modifier and indicate within the Remarks section of the claim “late RAP due to NYS ; Medicaid TPL demand billing request” and;
- Follow all outlined instructions within the Demand Bill Directive pertaining to timely and complete submission of information and documentation to UMMS.
NGS and the U.S. Centers for Medicare and Medicaid Services (CMS) is allowing the above steps as a temporary fix for the submission of demand bills for which No-Pay RAPs were not previously submitted.
Future TPL Demand Bills Involving the Following Dates of Service in 2021 (April 1 – September 30, 2021)
Sometime in March of 2022, HCA expects the OMIG / UMMS to send another letter identifying which cases have been selected to undergo the next round of appeals (through demand billing). The dates of service will span the third and fourth quarters of FFY 2021 only (April 1, 2021 through September 30, 2021) or the end of the episodic period billed to Medicaid.
For TPL cases with dates of services from April 1 through September 30, 2021, NGS will allow, CHHAs to use the three steps listed just above involving the KX modifier and indicate within the Remarks section of the claim “late RAP due to NYS; Medicaid TPL demand billing request.”
Future TPL Demand Bills Involving the Following Dates of Service in 2021-2022 (October 1, 2021 – March 30, 2022)
Then again, sometime in September of 2022, HCA expects the OMIG/UMMS to send another letter identifying which cases have been selected to undergo the subsequent round of appeals (through demand billing). The dates of service will span the first and second quarters of FFY 2022 only (October 1, 2021 through March 31, 2022) or the end of the episodic period billed to Medicaid.
For TPL cases with dates of services from October 1 through December 31, 2021, the OMIG and NGS accept CHHAs to have prospectively submitted a No-Pay RAP within the 5-day submission requirement (even in cases where the CHHA billed Medicaid). Since this No-Pay RAP is already submitted, CHHAs will just need to submit the TPL demand bill claim to NGS (Medicare) for its review.
NGS has told HCA that in cases where CHHAs prospectively submit a No-Pay RAP to Medicare (especially in cases where the CHHA intends to bill Medicare), other Medicare providers or entities (such as Durable Medical Equipment suppliers or outpatient therapy providers), will still be able to submit claims to Medicare for services provided to that dual-eligible beneficiary and get paid by Medicare since the No-Pay RAP submitted to NGS by the CHHA did not involve any monies be allocated to that CHHA.
In cases, where the CHHA hears from these other Medicare entities with concerns about the Medicare common working file (CWF) and the dual-eligible beneficiary possibly being in a Medicare home health episode (involving consolidated billing), the CHHA should instruct those other Medicare entities to bill Medicare for those services provided and Medicare will pay, since the No-Pay RAP submitted by the CHHA did not involve any prospective Medicare payment.
For TPL cases with dates of services from January 1, 2022 through March 31, 2022, the OMIG and NGS accept CHHAs to have prospectively submitted a Notice of Admission (NOA) claim within the 5-day submission requirement (even in cases where the CHHA billed Medicaid). Since this No-Pay RAP is already submitted, CHHAs will just need to submit the TPL demand bill claim to NGS (Medicare) for its review.
HCA CHHA members can find additional information on this NOA claim process in the following sources:
- Medlearn Matters (MM) Article 2256
- MM Article 12424
- NGS’s Website at www.ngsmedicare.com; Select HH&H (for Home Health and Hospice) and New York State; Education Table; Home Health Billing and Home Health NOA Claim Submission.
HCA will update the membership as additional information becomes available.