june 2018 • medicare …€¦ · my. home health & hospice this newsletter should be shared...
TRANSCRIPT
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Medicare BulletinJurisdiction 15
J U N E 201 8 • W W W.C G S M ED I CAR E .C O M
Reaching Out to the Medicare
Community
© 2018 Copyright, CGS Administrators, LLC.
Medicare BulletinJurisdiction 15
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Bold, italicized material is excerpted from the American Medical Association Current Procedural Terminology CPT codes. Descriptions and other data only are copyrighted 2018 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.
MEDICARE BULLETIN • GR 2018-06 JUNE 2018 2
Contents
For Home Health ProvidersNew Online Education Course For Home Health Providers 3
For Hospice ProvidersHospice: Proposed Updates to the Wage Index and Payment Rates for FY 2019 3Reminder: Submitting Hospice Exceptions for Untimely Notices of Election (NOE) 4
For Home Health and Hospice ProvidersCGS Website Updates 5Changes to the Interactive Voice Response (IVR) and Computer Telephone Integration (CTI) and the Message 5Introducing the New Frequently Asked Questions (FAQs) Search Feature 7MLN Connects® Weekly News 7MM10397 (Revised): Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esMD) System 8MM10531 (Revised): Claims Processing Actions to Implement Certain Provisions of the Bipartisan Budget Act of 2018 9MM10624: Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2018 Update 12New Medicare Card Project – Important Updates 14Provider Contact Center (PCC) Training 14SE17035 (Revised): Medicare Fee-for-Service (FFS) Response to the 2017 California Wildfires 15SE17037 (Revised): Medicare Fee-for-Service (FFS) Response to the 2017 Southern California Wildfires 17Suspended Claims Reminder 20Upcoming Educational Events 21
New Medicare cards with new numbers.
Are you ready?#NewCardNewNumberLEARN MORE AT:
https://www.cms.gov/Medicare/New-Medicare-Card/index.html
COMING IN 2018!
https://www.cgsmedicare.com/mycgs/index.html
myCGS is a secure Internet-based application where you can view beneficiary eligibility, claims status, online remittances, financial information, and much more!
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For Home Health Providers
New Online Education Course For Home Health Providers
CGS now has an online education course available to educate home health providers on the top claim submission error code 38107. Your claims go to the Return to Provider (RTP) file with reason code 38107 when the Fiscal Intermediary Standard System (FISS) is unable to match the claims with a processed Request for Anticipated Payment (RAP).
If you’re a new user, access the Online Education Center Web page at https://www.cgsmedicare.com/medicare_dynamic/education/001.asp and create your profile, otherwise, simply enter your email address. Select the Home Health & Hospice button and select “Avoid Billing Error 38107 – No Matching RAP” to access the course. This course includes audio and screen examples and will guide you through the steps to ensure you avoid reason code 38107.
Avoid Medicare payment delays for reason code 38107 and share this information with your billing staff. This course and others can be accessed at your own convenience.
Refer to the Top Claim Submission Errors (Reason Codes) and How to Resolve at https://www.cgsmedicare.com/hhh/education/materials/cses.html for information about reason code 38107 and other top claim errors.
For Hospice Providers
Hospice: Proposed Updates to the Wage Index and Payment Rates for FY 2019
This article was previously published in the April 27, 2018, special edition of the MLN Connects® at https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2018-04-27-eNews-SE.html
On April 27, CMS issued a proposed rule that would update FY 2019 Medicare payment rates and the wage index for hospices serving Medicare beneficiaries. This rule also proposes changes to the Hospice Quality Reporting Program.
Proposed Rule Details:
yy Advancing My HealthEData: Request for Information from stakeholders
yy Burden reduction
yy Meaningful Measures
The Medicare Learning Network® (MLN), offered by the Centers for Medicare & Medicaid Services (CMS), includes a variety of educational resources for health care providers. Access Web-based training courses, national provider conference calls, materials from past conference calls, MLN articles, and much more.
Learn more about what the CMS MLN offers at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html on the CMS website.
MEDICARE LEARNING NETWORK®
A Valuable Educational Resource!
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yy Routine annual rate setting changes
yy Hospice regulations text changes due to the Bipartisan Budget Act of 2018
yy Improving transparency for patients
For More Information:
yy Proposed Rule: CMS will accept comments until June 26 - https://www.federalregister.gov/documents/2018/05/08/2018-08773/medicare-program-fy-2019-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting
yy Press Release - https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-04-27.html
See the full text of this excerpted CMS Fact Sheet (issued April 27) at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-04-27-3.html
For Hospice Providers
Reminder: Submitting Hospice Exceptions for Untimely Notices of Election (NOE)
When the receipt date on your NOE is more than 5 days after the admit date, your NOE is considered to be untimely. This means that those days, from admission to the day before the NOE was received, are not payable by Medicare. Hospices may file an exception request if the following exceptions apply.
yy Fires, flood, earthquakes, or other unusual events that inflict extensive damage to hospice’s ability to operate
yy An event that produces a data filing problem due to CMS or contractor system issues, beyond the control of the hospice
yy Newly Medicare-certified hospice that is notified of certification after Medicare certification date, or awaiting user ID from Medicare contractor; or
yy Other circumstances determined by the Medicare contractor or CMS to be beyond hospice’s control.
Documentation for Exception RequestsProviders must provide sufficient information in the REMARKS field (FISS Page 04) that clearly indicates all the circumstances and time frames supporting the exception request. If the information in the REMARKS field is not clear, CGS will request additional documentation. If requested, send any documentation that supports the reason why the NOE was untimely.
In cases where the NOE could not process because a prior hospice benefit period had not been terminated, submit a dated screen print of the beneficiary’s eligibility record showing the open benefit period. In addition, any documentation to support your contact with, or attempts to contact, the prior hospice may also support the exceptional circumstance. In these cases, your documentation must show that the NOE was submitted timely, and subsequently RTPd or rejected because of the open hospice benefit period. If, upon review, CGS determines that the NOE was not initially submitted timely, the exception may not be granted.
Resourcesyy Requesting an Exception for an Untimely NOE CGS Web page - https://www.cgsmedicare.com/hhh/education/materials/requesting_exception_untimely_noes.html
yy SE1633, Exceptions For Late Hospice Notices of Election Delayed by Medicare Systems - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1633.pdf
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For Home Health and Hospice Providers
CGS Website Updates
CGS has recently made updates to their website, giving providers additional resources to assist with billing Medicare-covered services appropriately.
Please review the following updates:
yy The Home Health Top Medical Review Denial Reason Codes (https://www.cgsmedicare.com/hhh/medreview/hh_denial_reasons.html) and the Hospice Top Medical Review Denial Reason Codes (https://www.cgsmedicare.com/hhh/medreview/hos_denial_reasons.html) Web page were updated with the January – March 2018 denial data.
yy A new Hospice Documentation Checklist Tool quick resource tool at https://www.cgsmedicare.com/hhh/education/materials/pdf/j15_hospice_doc_checklistre.pdf was posted to the Hospice Quick Resource Tools Web page at https://www.cgsmedicare.com/hhh/education/materials/hospice_qrt.html. Use this tool to ensure you have all the necessary documentation for the Medicare hospice benefit.
yy The HHH Medical Review Additional Development Request Web page at https://www.cgsmedicare.com/hhh/medreview/adr_process.html was updated to add a link to the new Additional Development Request (ADR) Timeliness Calculator at https://www.cgsmedicare.com/hhh/medreview/adr_process.html in the Checking For MR ADRs section. The FISS Page 07 screen print was also updated due to the HIC field name changing to Medicare ID.
yy The adjustment process in the Medicare Secondary Payer Billing & Adjustments quick resource tool at https://www.cgsmedicare.com/hhh/education/materials/pdf/msp_billing.pdf was updated to include more details about Claim Change Reason Codes on page 17.
yy The Top Claim Submission Errors (Reason Codes) and How to Resolve Web page at https://www.cgsmedicare.com/hhh/education/materials/cses.html was updated with the most recent monthly data.
yy The Home Health and Hospice Recorded Webinars Web page at https://www.cgsmedicare.com/hhh/education/recorded_webinars.html was updated with links to access recordings of past events.
yy The Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) Guide Chapter 3: Inquiry Menu at https://www.cgsmedicare.com/hhh/education/materials/pdf/chapter_3-inquiry_menu.pdf and the Claims and Attachments Menu: Chapter 4 at https://www.cgsmedicare.com/hhh/education/materials/pdf/chapter_4-claims_and_attachments_menu.pdf have been updated.
yy The Claims Processing Issues Log Web page at https://www.cgsmedicare.com/hhh/claims/fiss_claims_processing_issues.html has been updated.
For Home Health and Hospice Providers
Changes to the Interactive Voice Response (IVR) and Computer Telephone Integration (CTI) and the Message
When you call the Part A, Part B, and Home Health and Hospice CGS Provider Contact Center (PCC) you will notice a change in the message when prompted to enter the beneficiary’s Medicare number.
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Updated IVR/CTI MessageOnce you have entered your provider identifying information, you will hear the following prompt.
yy Press 1 for the MBI or Press 2 for the HICN
What is an MBI?The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 mandates removal of the Social Security Number (SSN)-based Health Insurance Claim Number (HICN) from Medicare cards. The Medicare Beneficiary Identifier (MBI) is the new Medicare number that will replace the beneficiary’s HICN (also referred to as HIC number). All Medicare beneficiaries will receive a new Medicare card that includes a new MBI.
The MBI is a unique 11 character Medicare Number. CMS began mailing new Medicare cards with a new MBI in April 2018. Visit the New Medicare Cards (https://www.cms.gov/Medicare/New-Medicare-Card/index.html) and the CMS Mailing Strategy (https://www.cms.gov/Medicare/New-Medicare-Card/NMC-Mailing-Strategy.pdf) on the CMS website for Additional Information.
NEW Medicare Card with NEW Medicare Beneficiary Identifer (MBI)
Once the beneficiary receives their new Medicare card and MBI, you may start using it when accessing the IVR and CTI, and when submitting claims. However, either a HICN or MBI may be used during the transition period, April 2018 through December 31, 2019.
The IVR User Guide and the CTI User Guide have been updated with the new message prompts. These guides can be found on the Home Health and Hospice Customer Service, Phone/Fax Web page at https://www.cgsmedicare.com/hhh/cs/cs_phone_fax.html.
NEW Medicare Beneficiary Identifier (MBI) ConverterBecause the MBI is a mix of alpha/alpha-numeric characters, it can be difficult to enter the characters necessary for the IVR and CTI. To assist providers, CGS offers the Medicare Beneficiary Identifier (MBI) Converter at https://www.cgsmedicare.com/medicare_dynamic/j15/mbiconverter_j15hhh.asp on the CGS website. This converter will take the MBI number that you enter (no dashes) and provide you with the information you need to enter using the telephone keypad. Please note, this converter does not validate the beneficiary’s eligibility based on the MBI that you enter. However an error message will display if you enter an incorrect MBI number/alpha-numeric/numeric format.
myCGSRemember, myCGS (https://www.cgsmedicare.com/hhh/mycgs/index.html) is a great alternative to using the IVR to obtain eligibility, claim status, payment information and more. Visit the myCGS resources listed below for Additional Information. In addition, a Health Insurance Claim Number (HICN)/Medicare Beneficiary Identifier (MBI) Lookup tool will be provided in myCGS, so watch your email notifications for details on this exciting enhancement!
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This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff. Newsletters are available at no cost from our website at https://www.cgsmedicare.com. © 2018 Copyright, CGS Administrators, LLC.
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myCGS Resourceyy myCGS User Manual - https://www.cgsmedicare.com/mycgs/manual.html
yy Introducing…the myCGS MBI Look-Up Tool! - https://www.cgsmedicare.com/hhh/pubs/news/2018/0518/cope7584.html
For Home Health and Hospice Providers
Introducing the New Frequently Asked Questions (FAQs) Search Feature
CGS is excited to introduce a new search feature allowing providers to search only the FAQs. Simply enter the search term and any FAQ that includes that term will display, regardless of the FAQ topic. Here’s how it works.
The J15 HH&H FAQ Topics Web page at https://www.cgsmedicare.com/medicare_dynamic/faqs/J15hhh.asp, as well as each FAQ topic Web page, includes a search field for you to enter your search term. You may enter your search term either on the main FAQ page, or a specific FAQ topic page. Regardless, the same results will display the FAQs that include your search term.
The example below shows the home health and hospice (HH&H) FAQ search field with the search term “ADR.”
Once you click “Search HH&H FAQs” the FAQs that include “ADR” will display as well as the number of matching results. After reviewing the FAQs, you may enter another search term in the search field or click “Return to the full list of HH&H FAQ topics.”
With each FAQ that displays as a result of your search, the Topic in which the FAQ is housed will display, as well as the last published/reviewed/updated date. The example below shows that one of the 22 FAQs with the “ADR” search term, was found under the Comprehensive Error Rate Testing (CERT) Program topic, and was last reviewed on 3/26/2018.
If you have a question, take advantage of this new search feature before calling the Provider Contact Centers for assistance. Please share this information with your staff.
For Home Health and Hospice Providers
MLN Connects® Weekly News
The MLN Connects® is the official news from the Medicare Learning Network and contains a weeks worth of Medicare-related messages. These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. The following provides access to the weekly messages. Please share with appropriate staff. If you wish to receive the listserv directly from CMS, refer to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html.
yy April 12, 2018 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-04-12-eNews.pdf
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yy April 19, 2018 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-04-19-eNews.pdf
yy April 26, 2018 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-04-26-eNews.pdf
yy May 3, 2018 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-05-03-eNews.pdf
yy May 10, 2018 - https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-05-10-eNews.pdf
For Home Health and Hospice Providers
MM10397 (Revised): Modifications to the Implementation of the Paperwork (PWK) Segment of the Electronic Submission of Medical Documentation (esMD) System
The Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters Number: MM10397 RevisedRelated CR Release Date: April 3, 2018Related CR Transmittal Number: R2050OTN
Related Change Request (CR) Number: 10397Effective Date: July 1, 2018Implementation Date: July 2, 2018
Note: This article was revised on April 4, 2018, to reflect a revised CR issued on April 3. In the article, the CR release date, transmittal number, and the Web address of the CR are revised. All other information is the same.
Provider Type AffectedThis MLN Matters Article is intended for physicians, suppliers, and providers submitting electronic medical documentation to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action NeededChange Request (CR) 10397 updates the business requirements to enable MACs to receive unsolicited documentation (also known as paperwork (PWK)) via the Electronic Submission of Medical Documentation (esMD) system. CR10397 is for esMD purposes only. Please make sure your billing staffs are aware of these updates.
BackgroundCR10397 also contains attachments that include cover sheets that must be used for electronic, fax, or mail submissions of documentation. There are three cover sheets, one each for Part A and Part B providers, as well as one for durable medical equipment (DME) suppliers. In addition, there are two companion guides attached to CR10397, one for institutional claims and one for professional claims. A link to CR10397 is available in the Additional Information section of this article.
With CR10397, MACs will modify PWK, also known as unsolicited documentation procedures to include electronic submission(s) via esMD. Also, Medicare systems will accept PWK 02 values “EL” and “FT” for those MACs in a CMS-approved esMD system. This mechanism will suppress initial auto letter generation, if applicable, when PWK 02 is “EL” or “FT,” and is present at any level of the claim or line.
Providers will receive communication from MACs via companion documents for 5010 X12 837 to include:
yy The value “EL” (electronic) in PWK 02 to represent an esMD submission for sending the documentation using X12 Standards (6020 X12 275)
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yy The value “FT” (file transfer) in PWK 02 to represent an esMD submission for sending the documentation in PDF format using XDR specifications.
MACs will allow 7 calendar “waiting days” (from the date of receipt) for Additional Information to be submitted when the PWK 02 value is “EL” or “FT.”
MACs will use RC Client to reject the PWK data submissions as administrative error(s) when the received cover sheet (via esMD) is incomplete or incorrectly filled out as applicable to current edits. Providers can expect to see new generic reason statements introduced to convey these errors as follows (Codes for these statements will be finalized and sent along with the RC implementation guide):
yy The date(s) of service on the cover sheet received is missing or invalid.
yy The NPI on the cover sheet received is missing or invalid.
yy The state where services were provided is missing or invalid on the cover sheet received.
yy The Medicare ID on the cover sheet received is missing or invalid.
yy The billed amount on the cover sheet received is missing or invalid.
yy The contact phone number on the cover sheet received is missing or invalid.
yy The beneficiary name on the cover sheet received is missing or invalid.
yy The claim number on the cover sheet received is missing or invalid.
yy The Attachment Control Number (CAN) on the cover sheet is missing or invalid.
Once again, examples of the cover sheet are included as an attachment to CR10397.
Additional InformationThe official instruction, CR 10397, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2050OTN.pdf.
The X12 837 Companion Guides are available at https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/CompanionGuides.html.
If you have any questions, please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
Document History
Date DescriptionApril 3, 2018 The article was revised to reflect a revised CR. In the article, the CR release date, transmittal
number, and the Web address of the CR are revised. All other information is the same.February 16, 2018 Initial article released.
For Home Health and Hospice Providers
MM10531 (Revised): Claims Processing Actions to Implement Certain Provisions of the Bipartisan Budget Act of 2018
The Centers for Medicare & Medicaid Services (CMS) revised the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters Number: MM10531 RevisedRelated CR Release Date: April 4, 2018Related CR Transmittal Number: R2051OTNRelated Change Request (CR) Number: 10531
Effective Date: January 1, 2018Implementation Date: April 2, 2018 – date to begin reprocessing claims
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Note: This article was revised on April 5, 2018, to reflect a revised CR10531, which was revised on April 4 to include page 2 of Attachment B - Rural Add on Rate Tables. In the article, the CR release date, transmittal number, and the Web address for CR10531 are revised. All other information remains the same.
Provider Type AffectedThis MLN Matters Article is intended for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
What You Need to KnowChange Request (CR) 10531 provides direction to MACs to reprocess claims related to several provisions of the Bipartisan Budget Act of 2018, referred to as Medicare Extenders. Specifically, the CR provides guidance to MACs regarding Medicare Fee For Service (FFS) claims reprocessing requirements and timeframes. Make sure your billing staffs are aware of these changes.
BackgroundOn February 9, 2018, Congress passed the Bipartisan Budget Act of 2018 which contains a number of provisions that extend certain Medicare FFS policies, including Ambulance add-on payment provisions, the Work Geographic Practice Cost Index (GPCI) Floor, and the three percent Home Health (HH) Rural Add-on Payment. In addition, the Act permanently repeals the outpatient therapy caps beginning on January 1, 2018, while retaining the requirement to submit the KX modifier for services in excess of the prior cap amounts. Due to the retroactive effective dates of these provisions, your MAC will reprocess various Medicare FFS claims impacted by this legislation.
Section 421(a) of the Medicare Modernization Act (MMA), as amended by Section 50208 of the Social Security Act, provides an increase of 3 percent of the payment amount otherwise made under Section 1895 of the Social Security Act for home health services furnished in a rural area (as defined in Section 1886(d)(2)(D) of the Act), with respect to episodes and visits ending on or after April 1, 2010, and before January 1, 2019. The statute waives budget neutrality related to this provision.
As a result of the Work GPCI floor changes, certain Federally Qualified Health Center (FQHC) Geographic Adjustment Factors (GAFs) will change, which may result in a change to some FQHC payments. For Inpatient Prospective Payment System (IPPS) hospitals, temporary changes to the low-volume hospital payment adjustment and the Medicare-Dependent Hospital (MDH) program have been extended. In addition, for the Long-Term Care Hospital Prospective Payment (LTCH PPS), the blended payment rate for site neutral payment rate cases is extended for certain LTCH hospital discharges. Separate instructions addressing these payment updates are forthcoming.
On January 25, 2018, the Centers for Medicare & Medicaid Services (CMS) instructed MACs to release for processing held therapy claims with the KX modifier with dates of receipt January 1- 10, 2018. CMS also instructed the MACs to institute a “rolling hold” for all new therapy claims with the KX modifier. On February 12, 2018, CMS provided direction regarding new Medicare Physician Fee Schedule (MPFS) files and abstract files due to the extension of the Work GPCI Floor, as well as a revised 2018 Ambulance Fee Schedule (AFS) file. CMS also instructed the MACs to ensure legislative effective indicators were set correctly in Medicare systems to apply therapy policies. Given that legislation has been enacted, CMS is instructing the MACs to reprocess effected claims that were processed using the previous MPFS files.
As stipulated in Section 421(a) of the MMA, the 3 percent rural add-on is applied to the national, standardized episode rate, national per-visit payment rates, Low-Utilization Payment Adjustment (LUPA) add-on payments, and the Non-Routine Supplies (NRS) conversion factor when home health services are provided in rural (non-CBSA) areas for episodes and visits ending on or after April 1, 2010, and before January 1, 2019. Refer to Tables 1 through 4 of the attachment to CR10531 for the Calendar Year (CY) 2018 rural payment
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rates. CR10531 is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2047OTN.pdf.
Section 1848(e)(1)(E) of the Social Security Act stipulates that after calculating the work geographic index for purposes of MPFS payment for services furnished, the Secretary shall increase the work geographic index to 1.00 for any locality for which such work geographic index is less than 1.00. This provision expired on December 31, 2017, and the locality-specific anesthesia conversion factors for CY 2018 were calculated without this work geographic index floor of 1.00 in place.
Section 50201 of the Bipartisan Budget Act of 2018 restored the work geographic index floor of 1.00 and retroactively dated this restoration to January 1, 2018. In accordance with the law, CMS has updated the locality-specific anesthesia conversion factors for CY 2018 to include the work geographic index floor of 1.00. These updated locality-specific anesthesia conversion factors also have a retroactive effective date of January 1, 2018.
CR10531 reminds the MACs to be aware that Section 1848(b)(4) of the Social Security Act limits MPFS payment for the technical portion of most imaging procedures to the amount paid under the Outpatient Prospective Payment System (OPPS) system. This policy applies to the technical component (and technical portion of global payment) of imaging services, including X-ray, ultrasound, nuclear medicine, MRI, CT, and fluoroscopy services. The MPFS payment rates for some of these services does not reflect the most recent updates to the OPPS rates that were updated in December of 2017. CMS corrected these rates in new MPFS files and informed the MACs of the corrections on February 12, 2018. These MPFS files also contain the updates for the GPCI. This correction is unrelated to the passage of this Act, but CMS is taking the opportunity to address this issue now since new MPFS files are required as a result of the Act.
The instructions to the MACs to reprocess claims contain the following specifics:
yy The MACs will reprocess therapy claims with the KX modifier containing Dates of Service in Calendar Year 2018, which were denied prior to the implementation of the updated legislative effective dates issued on January 25, 2018. Note: For institutional claims, these claims will include revenue codes 042x, 043x, or 044x and modifiers GN, GO, or GP.
yy The MACs will reprocess therapy claims with the KX modifier which were denied due to an invalid date provided by CMS on February 12, 2018.
yy The MACs will reprocess 2018 therapy claims which cannot be automatically reprocessed only if you bring such claims to the attention of your MAC.
yy The MACs reprocess MPFS claims for localities and States impacted by the Work GPCI Floor fee increase for Dates of Service in CY 2018. Please refer to the chart in Attachment A - Localities and States Impacted by the Work GPCI Floor – 2018 – in CR10531.
yy The MACs will reprocess 2018 MPFS claims for localities and States impacted by the Work GPCI Floor fee increase for Dates of Service in CY 2018 which cannot be automatically reprocessed only if you bring such claims to your MAC’s attention. Please refer to the chart in Attachment A - Localities and States Impacted by the Work GPCI Floor – 2018.
yy The MACs will reprocess ground AFS claims using the revised 2018 AFS file for Dates of Service in Calendar Year 2018.
yy The MACs will reprocess claims which cannot be automatically reprocessed only if you bring such claims to your MAC’s attention.
yy MACs will reprocess home health claims with the following criteria:
y� Type of Bill 32X
y� Claim “Through” dates on or after January 1, 2018
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y� Value code 61 amounts in the range 999xx
y� Receipt dates prior to the installation of the revised home health Pricer, which reflects the extension of the 3% rural add-on for CY 2018.
yy MACs will automatically reprocess claims impacted by the OPPS cap for Dates of Service in Calendar Year 2018. The MACs will reprocess claims which cannot be automatically reprocessed only if you bring such claims to your MAC’s attention.
yy The MACs will automatically reprocess anesthesia claims for localities and States impacted by the Work GPCI Floor fee increase for Dates of Service in CY 2018. Please refer to the chart in Attachment A - Localities and States Impacted by the Work GPCI Floor – 2018. The MACs will reprocess claims which cannot be automatically reprocessed only if you bring such claims to your MAC’s attention.
yy MACs shall ensure all reprocessing actions have been initiated within 6 months of the issuance of CR10531:
y� For therapy and MPFS adjustments
y� For ground ambulance service claims with a date of service on or after 1/1/2018
y� For OPPS adjustments
y� For anesthesia adjustments
yy MACs shall ensure all reprocessing actions have been initiated within 6 months of the implementation date of the Pricer for HH rural add-on adjustments.
Additional InformationThe official instruction, CR10531, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2051OTN.pdf.
If you have any questions, please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
Document History
Date DescriptionApril 5, 2018 The article was revised to reflect a revised CR10531, which was revised to include page 2
of Attachment B - Rural Add on Rate Tables. In the article, the CR release date, transmittal number, and the Web address for CR10531 are revised. All other information remains the same.
March 26, 2018 Initial article released.
For Home Health and Hospice Providers
MM10624: Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2018 Update
The Centers for Medicare & Medicaid Services (CMS) issued the following Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters Number: MM10624Related CR Release Date: April 20, 2018Related CR Transmittal Number: R4025CP
Related Change Request (CR) Number: 10624Effective Date: July 1, 2018Implementation Date: July 2, 2018
Provider Types AffectedThis MLN Matters Article is intended for physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
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Provider Action NeededChange Request (CR) 10624 informs MACs of updated drug/biological HCPCS codes. The HCPCS code set is updated on a quarterly basis. The July 2018 HCPCS file includes 4 new HCPCS codes: Q9991, Q9992, Q9993 and Q9995. Please make sure your billing staffs are aware of these updates.
BackgroundThe July 2018 HCPCS file includes four new HCPCS codes, which are payable by Medicare, effective for claims with dates of service on or after July 1, 2018. These codes are:
yy Q9991
y� Short Description: Buprenorph xr 100 mg or less
y� Long Description: Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg
y� Type of Service (TOS) Code: 1
y� Medicare Physician Fee Schedule Data Base (MPFSDB) Status Indicator: E
yy Q9992
y� Short Description: Buprenorphine xr over 100 mg
y� Long Description: Injection, buprenorphine extended-release (sublocade), greater than 100 mg
y� TOS Code: 1
y� MPFSDB Status Indicator: E
yy Q9993
y� Short Description: Inj., triamcinolone ext rel
y� Long Description: Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg
y� TOS Code: 1,P
y� MPFSDB Status Indicator: E
yy Q9995
y� Short Description: Inj. emicizumab-kxwh, 0.5 mg
y� Long Description: Injection, emicizumab-kxwh, 0.5 mg
y� TOS Code: 1
y� MPFSDB Status Indicator: E
Additional InformationThe official instruction, CR 10624, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4025CP.pdf.
If you have any questions, please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
Document History
Date DescriptionApril 20, 2018 Initial article released.
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For Home Health and Hospice Providers
New Medicare Card Project – Important Updates
This article was previously published in the April 5, 2018, issue of the MLN Connects® at https://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2018-04-05-eNews.pdf
CMS started mailing newly-designed Medicare cards with the new Medicare Beneficiary Identifier (MBI), or Medicare Number. People enrolling in Medicare for the first time will be among the first to get the new cards, no matter where they live. Current Medicare beneficiaries will get their new cards on a rolling basis over the coming months (https://www.cms.gov/Medicare/New-Medicare-Card/NMC-Mailing-Strategy.pdf). We will continue to accept the Health Insurance Claim Number (HICN) through the transition period (https://www.cms.gov/Medicare/New-Medicare-Card/index.html#target).
During our planning, we continuously adjusted and improved our mailing strategy to make sure we are:
yy Mailing the new cards to accurate addresses
yy Protecting current Medicare beneficiaries and their personal information in every way possible
We are working on making our processes even better by using the highest levels of fraud protection when we mail new cards to current Medicare beneficiaries. Over the next few weeks, we will complete this additional work and begin mailing new cards to current Medicare beneficiaries.
We are committed to mailing new cards to all Medicare beneficiaries over the next year. For more information, visit the New Medicare Card landing (https://www.cms.gov/medicare/new-medicare-card/nmc-home.html) and provider (https://www.cms.gov/Medicare/New-Medicare-Card/Providers/Providers.html) Web pages.
For Home Health and Hospice Providers
Provider Contact Center (PCC) Training
Medicare is a continuously changing program, and it is important that we provide correct and accurate answers to your questions. To better serve the provider community, the Centers for Medicare & Medicaid Services (CMS) allows the provider contact centers the opportunity to offer training to our customer service representatives (CSRs). The list below indicates when the home health and hospice PCC at 1.877.299.4500 (option 1) will be closed for training.
Date PCC Training/ClosuresThursday, June 14, 2018 PCC Closed 8:00 – 10:00 a.m. Central TimeThursday, June 28, 2018 PCC Closed 8:00 – 10:00 a.m. Central Time
The Interactive Voice Response (IVR) (1.877.220.6289) is available for assistance in obtaining patient eligibility information, claim and deductible information, and general information. For information about the IVR, access the IVR User Guide at https://www.cgsmedicare.com/hhh/help/pdf/IVR_User_Guide.pdf on the CGS website. In addition, CGS’ Internet portal, myCGS, is available to access eligibility information through the Internet. For Additional Information, go to https://www.cgsmedicare.com/hhh/index.html and click the “myCGS” button on the left side of the Web page.
For your reference, access the “Home Health & Hospice 2018 Holiday/Training Closure Schedule” at https://www.cgsmedicare.com/hhh/help/pdf/2018_hhh_calendar.pdf for a complete list of PCC closures.
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For Home Health and Hospice Providers
SE17035 (Revised): Medicare Fee-for-Service (FFS) Response to the 2017 California Wildfires
The Centers for Medicare & Medicaid Services (CMS) revised the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters Number: SE17035 RevisedRelated CR Release Date: April 2, 2018Related CR Transmittal Number: N/A
Related Change Request (CR) Number: N/AEffective Date: N/AImplementation Date: N/A
Note: This article was revised on April 2, 2018, to advise providers that the public health emergency declaration and Section 1135 waiver authority expired on January 5, 2018. All other information remains the same.
Provider Types AffectedThis MLN Matters® Special Edition Article is intended for providers and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries, who were affected by the 2017 wildfires in the State of California.
Provider Information AvailablePursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, President Trump declared that, as a result of the effects of the 2017 Wildfires, a major disaster exists in the State of California.
On October 15, 2017, Acting Secretary Hargan of the Department of Health & Human Services declared that a public health emergency exists in the State of California retroactive to October 8, 2017, and authorized waivers and modifications under §1135 of the Social Security Act.
On October 17, 2017, the Administrator of the Centers for Medicare & Medicaid Services (CMS) authorized waivers under §1812(f) of the Social Security Act for the State of California retroactive to October 8, 2017 for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of wildfires. Providers can request an individual Section 1135 waiver by following the instructions available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf. The Public Health Emergency declaration and Social Security Act waivers including the Section 1135 waiver authority expired on January 5, 2018.
Background
Section 1135 and Section 1812(f) WaiversAs a result of the aforementioned declaration, CMS has instructed MACs as follows:
Change Request (CR) 6451 (Transmittal 1784, Publication 100-04) issued on July 31, 2009, applies to items and services furnished to Medicare beneficiaries within the State of California retroactive to October 8, 2017, for the duration of the emergency. In accordance with CR6451, use of the “DR” condition code and the “CR” modifier are mandatory on claims for items and services for which Medicare payment is conditioned on the presence of a “formal waiver” including, but not necessarily limited to, waivers granted under either Section 1135 or Section 1812(f) of the Act.
The most current information can be found at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Wildfires.html.
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Also referenced below are Q&As that are applicable for items and services furnished to Medicare beneficiaries within the State of California. These Q&As are displayed in two files:
yy One file addresses policies and procedures that are applicable without any Section 1135 or other formal waiver. These policies are always applicable in any kind of emergency or disaster, including the current emergency.
yy Another file addresses policies and procedures that are applicable only with approved Section 1135 waivers or, when applicable, approved Section 1812(f) waivers. These Q&As are applicable for approved individual 1135 waivers requested by providers for California.
In both cases, the links below will open the most current document. The date included in the document filename will change as new information is added, or existing information is revised.
a. Q&As applicable without any Section 1135 or other formal waiver are available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf.
b. Q&As applicable only with a Section 1135 waiver or, when applicable, a Section 1812(f) waiver, are available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf.
Waiver for California
Under the authority of Section 1135 (or, as noted below, Section 1812(f)), CMS has issued the following waiver in the affected areas of California. Individual facilities do not need to apply for the following approved waiver.
Skilled Nursing Facilities
yy 1812(f): This waiver of the requirement for a 3-day prior hospitalization for coverage of a Skilled Nursing Facility stay provides temporary emergency coverage of Skilled Nursing Facility (SNF) services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of the wildfires. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (Blanket waiver for all impacted facilities).
yy In addition, the waiver provides temporary emergency coverage of SNF services that are not post-hospital SNF services under the authority in §1812(f) of the Social Security Act (the Act), for those people who are evacuated, transferred, or otherwise dislocated as a result of the effects in the State of California, in October 2017. In addition, this waiver provides authority under §1812(f) of the Act to provide coverage for extended care services which will not require a new spell of illness in order to renew provision of services by a SNF. These temporary emergency policies would apply to the timeframes specified in the waiver(s) issued under §1135 of the Act in connection with the effects of the wildfires in the State of California in October 2017. Accordingly, both the effective date and expiration date for these temporary emergency policies are the same as those specified pursuant to the §1135 waivers. Further, unlike the policies authorized directly under the §1135 waiver authority itself, the two policies described above would not be limited to beneficiaries who have been relocated within areas that have been designated as emergency areas. Instead, the policies would apply to all beneficiaries who were evacuated from an emergency area as a result of the effects of the wildfires in California in October 2017, regardless of where the “host” SNF providing post-disaster care is located.
Administrative Relief
Appeal Administrative Relief for Areas Affected by California Wildfires
If you were affected by the California wildfires and are unable to file an appeal within 120 days from the date of receipt of the Remittance Advice (RA) that lists the initial determination
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or will have an extended period of non-receipt of remittance advices that will impact your ability to file an appeal, please contact your Medicare Administrative Contractor.
Requesting an 1135 WaiverInformation for requesting an 1135 waiver can be found at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf.
More information is available in the 1135 Waiver Letter, which is posted in the Downloads section at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Wildfires.html.
Medicare Quality Reporting and Value-based Purchasing ProgramsCMS is granting exceptions under certain Medicare quality reporting and value-based purchasing programs to acute care hospitals, inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, long-term care hospitals, renal dialysis facilities, and ambulatory surgical centers located in areas affected by the devastating impacts of the Northern California wildfires since October 8, 2017, in and around counties in Northern California. For complete details of these exceptions, see the document posted at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Memo-Requirements-Facilities-CA-Wildfires.pdf.
Additional Information If you have any questions, please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
Document History
Date DescriptionApril 2, 2018 The article was revised to advise providers that the public health emergency declaration and
Section 1135 waiver authority expired on January 5, 2018.November 1, 2017 This article was revised to add information regarding the exceptions granted for certain
Medicare quality reporting and value-based purchasing programs.October 18, 2017 Initial article released.
For Home Health and Hospice Providers
SE17037 (Revised): Medicare Fee-for-Service (FFS) Response to the 2017 Southern California Wildfires
The Centers for Medicare & Medicaid Services (CMS) revised the following Special Edition Medicare Learning Network® (MLN) Matters article. This MLN Matters article and other CMS articles can be found on the CMS website at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html
MLN Matters Number: SE17037 RevisedRelated CR Release Date: April 2, 2018Related CR Transmittal Number: N/A
Related Change Request (CR) Number: N/AEffective Date: N/AImplementation Date: N/A
Note: This article was revised on April 2, 2018, to advise providers that the public health emergency declaration and Section 1135 waiver authority expired on March 3, 2018. All other information remains the same.
Provider Types AffectedThis MLN Matters® Special Edition Article is intended for providers and suppliers who submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries, who were affected by the December 2017 wildfires in the State of California.
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Provider Information AvailablePursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, President Trump declared that, as a result of the effects of the December 2017 Wildfires, an emergency exists in the State of California.
On December 11, 2017, Acting Secretary Hargan of the Department of Health & Human Services declared that a public health emergency (PHE) exists in the State of California retroactive to December 4, 2017, and authorized waivers and modifications under §1135 of the Social Security Act.
On December 13, 2017, the Administrator of the Centers for Medicare & Medicaid Services (CMS) authorized waivers under §1812(f) of the Social Security Act for the State of California retroactive to December 4, 2017 for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of wildfires. Providers can request an individual Section 1135 waiver by following the instructions available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf. The Public Health Emergency declaration and Social Security Act waivers including the Section 1135 waiver authority expired on March 3, 2018.
Background
Section 1135 and Section 1812(f) WaiversAs a result of the aforementioned declaration, CMS has instructed MACs as follows:
Change Request (CR) 6451 (Transmittal 1784, Publication 100-04) issued on July 31, 2009, applies to items and services furnished to Medicare beneficiaries within the State of California retroactive to December 4, 2017, for the duration of the emergency. In accordance with CR6451, use of the “DR” condition code and the “CR” modifier are mandatory on claims for items and services for which Medicare payment is conditioned on the presence of a “formal waiver” including, but not necessarily limited to, waivers granted under either Section 1135 or Section 1812(f) of the Act.
The most current information is available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Wildfires.html.
Also referenced below are Q&As that are applicable for items and services furnished to Medicare beneficiaries within the State of California. These Q&As are displayed in two files:
yy One file addresses policies and procedures that are applicable without any Section 1135 or other formal waiver. These policies are always applicable in any kind of emergency or disaster, including the current emergency.
yy Another file addresses policies and procedures that are applicable only with approved Section 1135 waivers or, when applicable, approved Section 1812(f) waivers. These Q&As are applicable for approved individual 1135 waivers requested by providers for California.
In both cases, the links below will open the most current document. The date included in the document filename will change as new information is added, or existing information is revised.
a. Q&As applicable without any Section 1135 or other formal waiver are available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf.
b. Q&As applicable only with a Section 1135 waiver or, when applicable, a Section 1812(f) waiver, are available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf.
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Waiver for CaliforniaUnder the authority of Section 1135 (or, as noted below, Section 1812(f)), CMS has issued the following waiver in the affected areas of California. Individual facilities do not need to apply for the following approved waiver.
Skilled Nursing Facilities
yy 1812(f): This waiver of the requirement for a 3-day prior hospitalization for coverage of a Skilled Nursing Facility stay provides temporary emergency coverage of Skilled Nursing Facility (SNF) services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of the wildfires. In addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (Blanket waiver for all impacted facilities).
yy In addition, the waiver provides temporary emergency coverage of SNF services that are not post-hospital SNF services under the authority in §1812(f) of the Social Security Act (the Act), for those people who are evacuated, transferred, or otherwise dislocated as a result of the effects in the State of California, in December 2017. In addition, this waiver provides authority under §1812(f) of the Act to provide coverage for extended care services which will not require a new spell of illness in order to renew provision of services by a SNF. These temporary emergency policies would apply to the timeframes specified in the waiver(s) issued under §1135 of the Act in connection with the effects of the wildfires in the State of California in December 2017. Accordingly, both the effective date and expiration date for these temporary emergency policies are the same as those specified pursuant to the §1135 waivers. Further, unlike the policies authorized directly under the §1135 waiver authority itself, the two policies described above would not be limited to beneficiaries who have been relocated within areas that have been designated as emergency areas. Instead, the policies would apply to all beneficiaries who were evacuated from an emergency area as a result of the effects of the wildfires in California in December 2017, regardless of where the “host” SNF providing post-disaster care is located.
Administrative Relief
Appeal Administrative Relief for Areas Affected by California Wildfires
If you were affected by the California wildfires and are unable to file a timely appeal, respond to pending requests for documentation, or experience an interruption in the receipt of the Remittance Advice (RA) that lists the initial determination(s), please contact your MAC.
Requesting an 1135 WaiverInformation for requesting an 1135 waiver is available at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf.
More information is available in the 1135 Waiver Letter, which is posted in the Downloads section at https://www.cms.gov/About-CMS/Agency-Information/Emergency/Wildfires.html.
Additional InformationIf you have any questions, please contact a CGS Customer Service Representative by calling the CGS Provider Contact Center at 1.877.299.4500 and choose Option 1.
Document History
Date DescriptionApril 2, 2018 The article was revised to advise providers that the public health emergency declaration and
Section 1135 waiver authority expired on March 3, 2018.December 18, 2017 Initial article released.
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For Home Health and Hospice Providers
Suspended Claims Reminder
The Home Health and Hospice Provider Contact Center (PCC) have received an increase in calls from providers with questions about claims that are in a suspended status/location. This article serves as a reminder about how claims process through the Fiscal Intermediary Standard System (FISS).
As billing transactions processes in FISS, they move through various stages of the system. Each stage is identified by a status/location that can provide information about what’s happening to the claim.
Status Code “S” and LocationsThe status code “S” means the claim is suspended for processing. Locations further define what is happening with the billing transaction. Locations are 5-character positions. There are thousands of status/location combinations. Listed below are the most common status/location combinations and what they mean.
Status/Location “X” denotes various alpha/numeric characters DescriptionS B0100 System processing (billing transaction is suspended).S B6000 Billing transaction goes to this location for 1 day, prior to moving to S B6001 to generate the
additional development request (ADR). S B6001 Additional information is being requested from the provider. An Additional Development
Request (ADR) will be generated from this location. Documentation in response to Medical Review ADRs (MR ADRs) must be received by CGS within 45 calendar days. Refer to the Additional Development Request (ADR) Overview Web page at https://www.cgsmedicare.com/hhh/claims/overview_adr.html for additional information.
S M50MR Medical review of documentation. The billing transaction will move to this location after the Additional Development Request (ADR) information has been received. Please note that the review process may take up to 30 days to complete or 60 days for demand denials (condition code 20).
S B90XX Data on the billing transaction is being verified with the beneficiary eligibility information posted at the Common Working File (CWF).
S MXXXX Billing transactions are suspended in this location when Medicare staff intervention is needed. May be suspended for about 30 days. (See below for additional information.)
S M87DR Hospice Only – acknowledgement that CGS has received the documentation for an exception request for an untimely notice of election. Refer to the "Requesting an Exception for an Untimely NOE" Web page at https://www.cgsmedicare.com/hhh/education/materials/requesting_exception_untimely_noes.html for additional information.
S M87RE Hospice Only – the documentation provided in the Remarks field for an exception request for an untimely notice of election is being reviewed.
S M8877 Hospice Only – if documentation for an exception request for an untimely notice of election is not received within 30 days of the initial request, the claim will move to this status/location until day 45, or until your documentation is received. If documentation is not received by day 46, the claim will be released to process as billed. Refer to the "Requesting an Exception for an Untimely NOE" Web page at https://www.cgsmedicare.com/hhh/education/materials/requesting_exception_untimely_noes.html for additional information.
S MRADJ MSP adjustment – created after MSP adjustment received: awaiting completion.T B9900 Billing transaction will need correction by the provider when it moves into T B9997 in the
next system cycle.T B9997 Billing transaction needing correction by providers will appear in this location. Refer to the
Fiscal Intermediary Standard System Guide, "Chapter Five: Claims Correction" at https://www.cgsmedicare.com/hhh/education/materials/pdf/Chapter_5-Claims_Correction_Menu.pdf for information about correcting billing transactions. Assistance is also available on the "Top Claim Submission Errors (Reason Codes) and How to Resolve" Web page at https://www.cgsmedicare.com/hhh/education/materials/cses.html.
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Status/Location “X” denotes various alpha/numeric characters DescriptionI B9900 Billing transactions that are inactivated from Return to Provider (RTP) file; waiting to purge
from FISS.R B9997 Rejected billing transaction (finalized).R B75XX Rejected billing transaction (suspended). It may take at least 75 days for the claim to move
to the R B9997 finalized status/location.D B9997 Denied claim (all services denied). A partially denied claim will appear in the P status.P B7501 Post-pay MSP review.P B7505 Post-pay MSP review.P O9998 Archived claim. Refer to the Fiscal Intermediary Standard System Guide, "Chapter
Five: Claims Correction" at https://www.cgsmedicare.com/hhh/education/materials/pdf/Chapter_5-Claims_Correction_Menu.pdf for information about accessing archived claims.
P B9996 Billing transactions have been posted and are awaiting the payment floor.P B9997 Billing transactions have been processed and paid (full or partial).
Note: Claims with Medicare Secondary Payer (MSP) information may be suspended for more than 60 days. Providers may call the Provider Contact Center if a claim has been in the same “S MXXX” status/location for longer than 30 days, or 60 days for MSP claims.
To determine when a claim moved to the current status/location, access FISS Claim Page 02, and press F2. In the example below, this billing transaction moved to status/location S M50MR on March 28, 2018. Refer to the Checking Claim Status at https://www.cgsmedicare.com/hhh/claims/checking_claim_status.html for Additional Information.
MAP171D PAGE 02 CGS J15 MAC ACMFA552 MM/DD/YY XXXXXXX SC INST CLAIM INQUIRY C201821P HH:MM:SS DCN XXXXXXXXXXXXXXXXX HIC XXXXXXXXXXX RECEIPT DATE MMDDDYY TOB XXX STATUS S LOCATION M50MR TRAN DT 032818 STMT COV DT MMDDYY TO MMDDYY PROVIDER ID XXXXXXXXXX BENE NAME
As a reminder, the Medicare Claims Processing Manual (Pub. 100-04, Ch. 1, § 80.2.1.1) at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf states that Medicare contractors have 30 days to process clean claims. While the typical timeframe to process claims is less than this, contractors have the full 30 days from the receipt date of a clean claim to process it. Please note that home health Requests for Anticipated Payment (RAPs), hospice Notices of Election (NOEs) and adjustments have no specified timeframe for processing.
For Home Health and Hospice Providers
Upcoming Educational Events
The CGS Provider Outreach and Education department offers educational events through webinars and teleconferences throughout the year. Registration for live events is required. For upcoming events, please refer to the Calendar of Events Home Health & Hospice Education Web page at https://www.cgsmedicare.com/medicare_dynamic/wrkshp/pr/HHH_Report.asp. CGS suggests that you bookmark this page and visit it often for the latest educational opportunities.