OMIG Resumes Semiannual TPL Case Requests as HCA Works to Address Major Upcoming TPL Burden Involving No-Pay RAPs

Situation Report | March 29, 2021

The state Office of the Medicaid Inspector General (OMIG) has resumed its semi-annual demand-billing process for the second half of federal fiscal year (FFY) 2020 as part of the third-party liability (TPL) appeals initiative.

Importantly, HCA has also learned from the state’s TPL contractor — the University of Massachusetts Medical School (UMMS) — about major upcoming complications that we are working to address for future TPL case requests that will involve claims with the new no-pay Request for Anticipated Payment (RAP).

Below is a summary of the current TPL procedure followed by what’s anticipated for future appeals targeting claim periods involving no-pay RAPs — including HCA’s efforts to address this major new anticipated administrative burden.

Current Semiannual Appeals Request

Most Medicare-certified home care providers should have received a letter (dated March 16, 2021) from OMIG and UMMS identifying which cases have been selected to undergo the current round of appeals (through demand billing). The dates of service span the third and fourth quarters of FFY 2020 only (April 1, 2020 through September 30, 2020) 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 Medicare Administrative Contractor (MAC), National Government Services (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.

HCA members interested in knowing whether they should have received a letter from OMIG can e-mail HCA at

Important Info on Future TPL Initiatives and Submitting No-Pay RAPs

Since this current state TPL initiative (in the letter dated March 16) involves cases with dates of services between April 1 and September 30, 2020, impacted Medicare-certified agencies should continue to demand bill NGS with the regular RAP used prior to the January 1, 2021 implementation of no-pay RAPs as part of the Patient Driven Groupings Model (PDGM).

However, this policy of submitting RAPs to NGS is changing for future state TPL initiatives, according to TPL representatives from UMMS, due to the January 1, 2021 implementation of no-pay RAPs, which include payment penalties for submitting no-pay RAPs later than 5 days after the start of care (SOC) or admission date.

Starting with future retroactive appeal initiatives, UMMS has indicated that a no-pay RAP must also be submitted to NGS for all dually eligible cases — even for those cases where the Medicare-certified agency makes a determination that the dually eligible beneficiary does not meet the Medicare criteria for home health (for example: no skilled need or not homebound) and decides that Medicaid is the proper payor. This will need to be done within five days from the SOC or admission date, to avoid future payment penalties.

HCA has explained to UMMS and OMIG representatives the substantial administrative burden this will cause Medicare-certified agencies in the state. Because impacted agencies were unaware of this new TPL guidance until late March of 2021, dually eligible cases billed to Medicaid but selected by OMIG for the second quarter of FFY 2021 (January 1 through March 31, 2021) will not have had an opportunity to include a no-pay RAP within the five-day window, thus negating OMIG’s opportunity to potentially get paid by Medicare via the TPL demand-billing process.

Under the new procedures, beginning April 1, 2021 (the start of the third quarter FFY 2021), Medicare-certified agencies will be expected to submit no-pay RAPs to NGS within five days in all cases, even those where the agency determines Medicaid is the appropriate payor.

HCA has requested a meeting with OMIG’s new Medicaid Inspector General, Frank Walsh, and his TPL Team, including UMMS, to discuss all of the problems associated with this new no-pay RAP billing guidance as well as further anticipated complications once CMS eliminates the no-pay RAP at the end of calendar year 2021 and moves to a Notice of Admission (NOA) process for calendar year 2022.

HCA will update the membership as additional information becomes available and/or after our discussions with OMIG and UMMS.