NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by

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1 NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here.

2 JM HHH Medicare Advisory Latest Medicare News for JM Home Health & Hospice May 2017 Volume 2017, Issue 05 What s Inside... CMS e-news...2 Home Health Services Pre-Claim Review Demonstration Pause...2 Home Health and Hospice Information...3 There is Still Time to Evaluate Our Services!...3 July 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revision to Prior Quarterly Pricing Files...4 Denial of Home Health Payments When Required Patient Assessment Is Not Received Additional Information...5 eaudit to Generate Reports for Claims under Complex Medical Review!...7 Action Needed: Due to Increased CMS Security Requirements, eservices Portal Users Must Sign Up for Multi-Factor Authentication (MFA) by July 1, We d Love Your Feedback!...10 eservices Makes Asking a Medicare Question Easier!...12 Managing Multiple eservice Accounts Just Got Easier with Account Linking!...12 Get Your Medicare News Electronically...13 Medicare Learning Network (MLN)...13 CallBack Assist...14 Appeals Information...15 C2C Innovative Solutions, Inc.: Qualified Independent Contractor (QIC) for Part A East Jurisdictions...15 Learning and Education Information...16 Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA Jurisdiction M (JM) Home Health Medicare Workshop Series Jurisdiction M (JM) Hospice Medicare Workshop Series...19 Provider Enrollment Information...21 Provider Enrollment Revalidation Cycle Tools You Can Use...29 Medicare Credit Balance Report Module...29 Helpful Information...31 Contact Information for Palmetto GBA Home Health and Hospice...31 palmettogba.com/hhh The JM HHH Medicare Advisory contains coverage, billing and other information for Jurisdiction M HHH. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the guidelines. The JM HHH Medicare Advisory includes information provided by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost from our website at CPT only copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright 2012 American Dental Association (ADA). All rights reserved.

3 Please Register for a 2017 Home Health or Hospice Workshop Session The 2017 Home Health Workshop series and the 2017 Hospice Workshop Series are well underway. For more information abouth these workshops and registration instructions, please go to Page 17 for home health and Page 19 for hospice. CMS E-NEWS CMS e-news will contain a week s worth of Medicare-related messages from the Centers of Medicare & Medicaid Services (CMS). These messages ensure planned, coordinated messages are delivered timely about Medicare-related topics. Please share with appropriate staff. To view the most recently issues, please copy and paste the following links into your Web browser: April 20, pdf April 13, pdf April 6, pdf March 30, pdf Home Health Services Pre-Claim Review Demonstration Pause As of April 1, 2017, the Pre-Claim Review demonstration for home health services is paused in Illinois and didn t expand to Florida. We will process claims under normal processing rules. The Centers for Medicare & Medicaid Services will notify providers at least 30 days in advance of further developments related to the demonstration. For more information, see the Pre-Claim Review Demonstration ( research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/preclaim-review-initiatives/overview.html) webpage and FAQs ( Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review- Initiatives/Downloads/Pre-Claim_Review_Pause_QandAs_ pdf). 2 05/2017

4 HOME HEALTH AND HOSPICE INFORMATION There is Still Time to Evaluate Our Services! There is still time to share your experiences about the services we provide. Please complete the MAC Satisfaction Indicator (MSI) survey. These survey results will help us find ways to better serve you. To take the survey, go to: Palmetto Thank you for the feedback provided to us throughout We made a lot of improvements to our services and have more planned in the coming months. In response to the provider feedback we created the following educational resources and enhancements: Developed Home Health & Hospice EDI Enrollment Instructions Guide Module Developed Provider Enrollment Training Modules o Home Health & Hospice Provider Enrollment 101 Module o Home Health & Hospice Provider Enrollment PECOS Module Enhanced the Website Search Feature: Updated the web content manager algorithm to assure the newest postings display first as new items are posted Computer Telephony Integration (CTI) or screen pop was implemented in January of This technology enables our Interactive Voice Response Unit (IVR) to interact with our inquiry tracking system. Providers using the IVR enter their NPI, PTAN and tax identification number along with beneficiary information for claim specific inquiries. Your provider and claim specific information auto-populates the Customer Service Associate s (CSA) inquiry record eliminating the need for you to repeat the information to the CSA. Please ensure you provide this information as prompted each and every time to call our consolidated toll-free number. You are able to press 0 at any time in the IVR to reach a CSA. This opt-out feature allows the caller to speak directly with a CSA when the inquiry is complex or the caller knows the information needed is not available in the IVR. It is important to note that the caller will be referred back to the IVR for information that is available in the IVR. When you opt-out of the IVR, you will be prompted to provide your provider specific and claim information. It is important to supply all information when prompted so the CSA receives your information as soon as your call is answered. We continue to streamline the IVR messages to reduce the number of messages and to provide options for bypassing the message. This is an ongoing effort that is projected for completion by the end of June. 3 05/2017

5 Our Outreach and Education Team heard the provider community feedback about wanting more opportunities for questions and answers and as a result, we have started highlighting these monthly offerings in our Medicare Advisory in a section called Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA. We hope you will consider attending some of our events this year. Thank you for your feedback. July 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revision to Prior Quarterly Pricing Files MLN Matters Number: MM10016 Related CR Release Date: April 7, 2017 Related CR Transmittal Number: R3746CP Related Change Request (CR) Number: Effective Date: July 1, 2017 Implementation Date: July 3, 2017 Provider Type Affected This MLN Matters Article is intended for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries. Provider Action Needed Change Request (CR) 9945 provides the July 2017 quarterly update and instructs MACs to download and implement the July 2017 ASP drug pricing files and, if released by the Centers for Medicare & Medicaid Services (CMS), the revised April 2017, January 2017, October 2016, and July 2016 Average Sales Price (ASP) drug pricing files for Medicare Part B drugs. Medicare will use these files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after July 3, 2017, with dates of service July 1, 2017, through September 30, MACs will not search and adjust claims previously processed unless brought to their attention. Background The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply contractors with the ASP and Not Otherwise Classified (NOC) drug-pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the OPPS are incorporated into the Outpatient Code Editor (OCE) through separate instructions. The following files are related to this most recent update: July 2017 ASP and ASP NOC Effective Dates of Service: July 1, 2017, through September 30, 2017 April 2017 ASP and ASP NOC Effective Dates of Service: April 1, 2017, through June 30, 2017 January 2017 ASP and ASP NOC Effective Dates of Service: January 1, 2017, through March 31, 2017 October 2016 ASP and ASP NOC Effective Dates of Services: October 1, 2016, through December 31, /2017

6 July 2016 ASP and ASP NOC Effective Dates of Service: July 1, 2016, through September 30, 2016 For any drug or biological not listed in the ASP or NOC drug-pricing files, MACs will determine the payment allowance limits in accordance with the policy described in the Medicare Claims Processing Manual, Chapter 17, Section , which is available at Guidance/Guidance/Manuals/Downloads/clm104c17.pdf. For any drug or biological not listed in the ASP or NOC drug-pricing files that is billed with the KD modifier, contractors shall determine the payment allowance limits in accordance with instructions for pricing and payment changes for infusion drugs furnished through an item of Durable Medical Equipment (DME) on or after January 1, 2017, associated with the passage of the 21st Century Cures Act. Additional Information The official instruction issued to your MAC regarding this change is available at Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3746CP.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Document History Date of Change April 7, 2017 Description Initial Article Released Denial of Home Health Payments When Required Patient Assessment Is Not Received Additional Information MLN Matters Number: SE17009 Article Release Date: March 24, 2017 Related CR Transmittal Number: R3629CP Related Change Request (CR) Number: 9585 Effective Date: April 1, 2017 Implementation Date: April 3, 2017 Provider Type Affected This MLN Matters Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for home health services provided to Medicare beneficiaries. 5 05/2017

7 Provider Action Needed In Change Request (CR) 9585, the Centers for Medicare & Medicaid Services (CMS) directed MACs to automate the denial of Home Health Prospective Payment System (HH PPS) claims when the condition of payment for submitting patient assessment data has not been met. CR9585 is effective on April 1, This article is a reminder of the upcoming change and provides further information to assist HHAs in avoiding problems with these Medicare requirements. Make sure that your billing staffs are aware of this change. Background Per the Code of Federal Regulations (CFR) at 42 CFR (e) ( title42-vol5/pdf/CFR-2011-title42-vol5-part484.pdf), submission of an Outcome and Assessment Information Set (OASIS) assessment for all Home Health (HH) episodes of care is a condition of payment. In MLN Matters article MM9585 ( Network-MLN/MLNMattersArticles/Downloads/mm9585.pdf), Medicare notified HHAs that effective for claims with dates of service on or after April 1, 2017, Medicare systems will increase enforcement of this condition of payment. Claims Denied When an OASIS Assessment Has Not Been Submitted OASIS reporting regulations require the OASIS to be transmitted within 30 days of completion. In most cases, this 30-day period will have elapsed by the time a 60-day episode of HH services is completed and the HHA submits the final claim for that episode to Medicare. Upon receipt of a final claim with service dates after April 1, 2017, Medicare systems will check whether the corresponding OASIS assessment is present in the Quality Information and Evaluation System (QIES). If the OASIS assessment is not found AND the receipt date of the claim is more than 30 days after the assessment completion date reported on the claim, Medicare systems will deny the HH claim. While the regulation requires the assessment to be submitted within 30 days of completion, the initial implementation of this process will allow 40 days. Medicare systems will check for assessments used to determine the HIPPS code on the claim (Start of Care, Recertification and certain Resumption of Care assessments). Again, for the claim to be denied, the assessment must be both missing AND past due. When denying the claim, Medicare will apply the following remittance messages: Group Code of CO Claim Adjustment Reason Code 272 Refer to OASIS Validation Reports Before submitting an HH claim to your MAC, the HHA should ensure the OASIS assessment has completed processing and was successfully accepted into the QIES National Database. The HHA can verify this by reviewing their OASIS Agency Final Validation Report or OASIS Submitter Final Validation Report for the submission which included the assessment. This may require communication between the provider s billing office and their clinical staff that submits the OASIS to CMS. 6 05/2017

8 There is no need to call the QIES Technical Support Office (QTSO) help desk for such billing issues. The OASIS Agency Final Validation Report and OASIS Submitter Final Validation Report provide all the information needed (that is, confirmation of an assessment s receipt, the date of receipt, and any fatal or warning errors encountered) in order to prevent claims denials or to understand why a denial occurred. HHAs should ensure, prior to submission of the OASIS assessment and the claim, that the following information is correct: HHA CMS Certification Number (OASIS item M0010) Beneficiary Medicare Number (OASIS item M0063) Assessment Completion Date (OASIS item M0090) Reason for Assessment (OASIS Item M0100) equal to 01, 03 or 04 These items will be used to match claims and assessments, so accuracy of submission can help prevent claim denials. Additional Information You may also want to review MLN Matters Article MM9585, which is available at gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/ mm9585.pdf. If you have any questions, please contact your MAC at their toll-free number. That number is available at Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. Document History Date of Change March 24, 2017 Description Initial article released eaudit to Generate Reports for Claims under Complex Medical Review! Electronic Audit (eaudit) is a new function available in the eservices online portal, which allows providers the ability to access personal reports of audit results for claims which have been chosen for Complex Medical Review by various Medicare review contractors. eaudit gives providers the opportunity to see what claims may be pending Complex Medical Review currently and the results of any recent review decisions. This information can be used for self-assessment of provider performance on Medicare audits utilizing a dashboard which contains the most common denial reasons. The eaudit tool currently features CERT contractor claim review data with JM Medicare Administrative Contractor (MAC) Medical Review and JM Appeal review data coming soon! 7 05/2017

9 How do I use the eaudit function? To get started, log into the eservices portal using your user ID and select the eaudit tab, which is located under the ereview tab. The screen will automatically populate with a summary table of your CERT audit data by error code category. Full details can be found in the eservices User Guide. If you don t already have an eservice account, register for one today. Example of eaudit in eservices Action Needed: Due to Increased CMS Security Requirements, eservices Portal Users Must Sign Up for Multi-Factor Authentication (MFA) by July 1, 2017 Why You Need It: It s easier than you might think for someone to steal your password. Multi-factor authentication (MFA) can help your eservices account remain secure even if someone manages to obtain your password without your knowledge. How It Works: The eservices MFA is an extra layer of security. Users may log into eservices and access the My Account tab in order to turn on this optional feature. Once activated, signing into your eservices account will work a little differently: 8 05/2017

10 1. You ll enter your password as usual 2. Then, you ll select your preferred method of delivery between or a text message 3. Once you receive your verification code, you will enter it in the verification box and you re in 9 05/2017

11 Deadline to Sign Up: Providers have from now through March 31, 2017, to sign up for multi-factor authentication for each active user ID voluntarily. April 1, 2017 to June 31, 2017, providers will be required to sign up for multi-factor authentication at enrollment, password reset and recertification. Effective July 1, 2017, if you have not yet signed up for MFA, your account will automatically be set to MFA with the address associated with the user ID. Note: Providers who have linked their accounts will only need to sign up for MFA for their default account. eservices User Manual: Please see the eservices User Manual for more information. We d Love Your Feedback! Palmetto GBA is committed to continuously improve your customer experience. We welcome your feedback on your experiences with the PalmettoGBA.com website and the eservices portal. As a visitor to the Palmetto GBA s website, you may be presented with an opportunity to take the website satisfaction survey. The next time the survey is offered to you, please agree to participate and provide us with your feedback. You have the opportunity to explain your comments, share your honest opinions, and tell us what you like and what you would like to see us improve. If you find a feature or tool specifically helpful, let us know including any suggestions for making them simpler to use /2017

12 We continuously analyze your feedback and develop enhancements plans to better assist you with your experience. We value your opinion and look forward to hearing from you /2017

13 eservices Makes Asking a Medicare Question Easier! Palmetto GBA is pleased to announce the newest addition to our eservice options---secure echat! This innovative feature allows providers to interact with designated Palmetto GBA staff so they can receive realtime assistance locating information on any topics or specialties they are searching for on the Palmetto GBA website or within the eservices online portal. The Secure echat feature also allows users to dialogue with an online operator who can assist with patient or provider specific inquires or address questions that require the sharing of PHI information! Using Secure echat is simple! This free portal is available to all Medicare providers as long as you have a signed Electronic Data Interchange (EDI) Enrollment Agreement on file with Palmetto GBA. Once in the eservices portal, from the bottom right corner select either Medicare Inquiries or eservices Help. If you do not have an eservices account, you can get started by clicking this eservices link The Secure echat feature is available during business hours to assist providers. Managing Multiple eservice Accounts Just Got Easier with Account Linking! Palmetto GBA is excited to announce the highly anticipated eservice enhancement- Account Linking! No longer will providers need a separate login for each PTAN and NPI combination. Palmetto GBA now gives users the ability to link their previously assigned eservices user IDs under one default ID. Getting started is simple! Users should log into eservices with the user ID that they wish to designate as their default login ID. This is the user ID that will be used to access the linked accounts. Once the user has successfully logged into eservices, they will select the My Account Tab and then access the Account Linking sub-tab. This will allow the provider to choose the accounts they wish to link. Note: Providers are only able to link active eservices accounts. Once your accounts are linked you will be able to log in, click a drop down menu that lists all your linked NPI and PTAN combinations attached to your ID, and select the individual account you d like to view. For complete step-by-step instructions, please view the eservices User Guide external link ( palmettogba.com/eservicesuserguide) /2017

14 Get Your Medicare News Electronically The Palmetto GBA Medicare listserv is a wonderful communication tool that offers its members the opportunity to stay informed about: Medicare incentive programs Fee Schedule changes New legislation concerning Medicare And so much more! How to register to receive the Palmetto GBA Medicare Listserv: Go to and select Register Now. Complete and submit the online form. Be sure to select the specialties that interest you so information can be sent. Note: Once the registration information is entered, you will receive a confirmation/welcome message informing you that you ve been successfully added to our listserv. You must acknowledge this confirmation within three days of your registration. Medicare Learning Network (MLN) Want to stay informed about the latest changes to the Medicare Program? Get connected with the Medicare Learning Network (MLN) the home for education, information, and resources for health care professionals. The Medicare Learning Network is a registered trademark of the Centers for Medicare & Medicaid Services (CMS) and the brand name for official CMS education and information for health care professionals. It provides educational products on Medicare-related topics, such as provider enrollment, preventive services, claims processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of formats, including training guides, articles, educational tools, booklets, fact sheets, web-based training courses (many of which offer continuing education credits) all available to you free of charge! The following items may be found on the CMS web page at: index.html MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To access the catalog, scroll to the Downloads section and select MLN Catalog. Once you have opened the catalog, you may either click on the title of a product or you can click on the type of Formats Available. This will link you to an online version of the product or the Product Ordering Page /2017

15 MLN Product Ordering Page: allows you to order hard copy versions of various products. These products are available to you for free. To access the MLN Product Ordering Page, scroll to the Related Links and select MLN Product Ordering Page. MLN Product of the Month: highlights a Medicare provider education product or set of products each month along with some teaching aids, such as crossword puzzles, to help you learn more while having fun! Other resources: MLN Publications List: contains the electronic versions of the downloadable publications. These products are available to you for free. To access the MLN Publications go to: You will then be able to use the Filter On feature to search by topic or key word or you can sort by date, topic, title, or format. MLN Educational Products Electronic Mailing List To stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the MLN Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you will receive an when new and revised MLN products are released. To subscribe to the service: 1. Go to and select the Subscribe or Unsubscribe link under the Options tab on the right side of the page. 2. Follow the instructions to set up an account and start receiving updates immediately it s that easy! If you would like to contact the MLN, please CMS at MLN@cms.hhs.gov. CallBack Assist CallBack Assist was implemented to improve the wait times during peak calling periods of the day. CallBack Assist allows providers to opt out for a same-day callback from a customer service representative (CSR). Typically, the callback occurs within one hour. This feature is a contact center best practice among the industry. Providers are encouraged to try this new option when offered to avoid long wait times for assistance /2017

16 APPEALS INFORMATION C2C Innovative Solutions, Inc.: Qualified Independent Contractor (QIC) for Part A East Jurisdictions Beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions. Should a provider be dissatisfied with the results of a first-level appeal (redetermination), they may request a second-level decision. All second-level appeals, known as reconsiderations, must be conducted by Qualified Independent Contractors (QICs). Effective February 14, 2017, C2C Innovative Solutions, Inc. is the Qualified Independent Contractor (QIC) for the East Jurisdiction. The states under the C2C Innovative Solutions, Inc. jurisdiction include: East Jurisdiction ( Alabama, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Louisiana, Maine, Maryland, Massachusetts, Mississippi, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Texas, Vermont, Virginia, Virgin Islands and West Virginia Please note that a request for reconsideration must be filed within 180 days of the redetermination decision. To file this request, please follow instructions on the Medicare Redetermination Notice (MRN) for the completion of Form CMS external link ( CMS-Forms/downloads/cms20033.pdf) or complete a written request including the beneficiary s name, Medicare health insurance claim (HIC) number, dates of service, specific service(s) and item(s) for which reconsideration is requested, name and signature of the party or representative of the party, and the name of the contractor that made the redetermination. This request should be filed with the contractor responsible for the state in which the services were rendered. However, if you are a chain provider, ensure that your request is sent to the QIC who has jurisdiction in the state where the claim was processed. This reconsideration request, and any other correspondence with C2C Innovative Solutions, Inc., should be addressed to: C2C Innovative Solutions, Inc. QIC Part A East Appeals P.O. Box Jacksonville, FL /2017

17 LEARNING AND EDUCATION INFORMATION Educational Events Where You Can Ask Questions and Get Answers from Palmetto GBA Don t Miss this Wonderful Opportunity! If you are in search of an opportunity to interact with and get answers to your Medicare billing, coverage and documentation questions from Palmetto GBA s Provider Outreach and Education (POE) department, please see these educational offerings which have a question and answer session: Quarterly Ask the Contractor Teleconferences (ACTs) Quarterly Updates Webcasts Event Registration Portal ACTs are intended to open the communication channels between providers and Palmetto GBA, which allows for timely identification of problems and information-sharing in an informal and interactive atmosphere. These teleconferences will be held at least quarterly via teleconference. Preceding the presentation, providers are given an opportunity to ask questions both on the topics discussed as well as any other question they may have. While we encourage providers to submit questions prior to the call, this is not required. Just fill out the Ask the Contractor Teleconference (ACT): Submit A Question form). Once the form is completed, please fax it to (803) , Attention: Ask-the-Contractor Teleconference The Quarterly Update Webcasts are intended to provide ongoing, scheduled opportunities for providers to stay up to date on Medicare requirements. Providers are able to type a question and have it responded to by the POE department throughout the webcast. At the end of the presentation the moderator will also read and respond to questions submitted by attendees in order to share the responses with the group at large. Visit our Event Registration Portal to find information on upcoming educational events and seminars. This is a complete listing of both our face-to-face outreach opportunities as well as our teleconference and webcast listings. Providers are able to dialogue with POE and get answers to their questions at all of these educational events. If you have a question that you need an answer to today or a claims specific question which requires the disclosure of PII or PHI for response, please contact the Provider Contact Center (PCC) at /2017

18 2017 Jurisdiction M (JM) Home Health Medicare Workshop Series Palmetto GBA s 2017 Home Health Workshop Series, Getting It Right the First Time, is well underway. These workshops are designed for home health providers and their staff to equip them with the tools they need to be successful with Medicare billing, coverage and documentation requirements. These workshops will provide insight for home health agency staff at all levels; however, we suggest that providers who are new to Medicare or have new staff attend our online learning courses for beginners at Basic billing and other online educational resources can be found in the Self-Paced Learning section by selecting the Learning and Education link under the Browse Topics option at the top of the page. During the workshop series, Palmetto GBA will provide information related to the most common errors identified through a variety of data analysis and some hints and tips on the reasons why these errors occur. Palmetto GBA s ultimate goal is to have educated and astute providers who know how to accurately and skillfully apply the information they learn to their documentation and billing practices! The following topics will be covered during the workshop: Part I Date Analysis o Length of Stay (LOS) o High Risk Health Insurance Prospective Payment System (HIPPS) Codes Comprehensive Assessments Medical Review Program Medical Review Top Denials Occupational Therapy Speech Language Pathology Medical Social Services Part II What You Need to Know for 2017 Data Driven Topics 17 05/2017

19 Overlapping Dates of Service o Hospital Stays During an Episode o Transfer Requirements Billing Dispute Resolution Requests Comparative Billing Report (CBR) Comprehensive Error Rate Testing (CERT) Program Recovery Audit Contractor (RAC) Provider Enrollment Revalidation eservices Online Provider Portal Provider Resources/Self Service Tools o Secure echat o Tools and Calculators o Social Media o Updates o Pre-Claim Review Home Health Basics Modules How to Register The schedule of workshops is available on the Event Registration Portal under the Learning and Education section of the Palmetto GBA Home Health and Hospice webpage ( The state associations are sponsoring the workshops. Please select the link for the date of the workshop you want to attend and that will take you directly to the Association s registration page 18 05/2017

20 2017 Jurisdiction M (JM) Hospice Medicare Workshop Series Palmetto GBA s 2017 Hospice Workshop Series, Getting It Right the First Time, is well underway. These workshops are designed for hospice providers and their staff to equip them with the tools they need to be successful with Medicare billing, coverage and documentation requirements. These workshops will provide insight for hospice agency staff at all levels; however, we suggest that providers who are new to Medicare or have new staff attend online learning courses for beginners offered at Basic billing and other online educational resources can be found in the Self-Paced Learning section by selecting the Learning and Education link under the Browse Topics option at the top of the page. During the workshop series, Palmetto GBA will provide information related to the most common errors identified through a variety of data analysis and some hints and tips on the reasons why these errors occur. Palmetto GBA s ultimate goal is to have educated and astute providers who know how to accurately and skillfully apply the information they learn to their documentation and billing practices! The following topics will be covered during the workshop: Part I Data Analysis o Length of Stay (LOS) Screening New Patients for Hospice Interdisciplinary Group (IDG) Member Roles o Medical Director o Nurse o Social Worker o Pastoral Counselor Medical Review Program Medical Review Top Denials Dementia Patients Part II What You Need to Know for /2017

21 Data Driven Topics o Hospice Election Statement o Medicare Secondary Hospice Election o Transfer Requirements o Billing Dispute Resolution Requests o Comparative Billing Report (CBR) Comprehensive Error Rate Testing (CERT) Program Recovery Audit Contractor (RAC) Provider Enrollment Revalidation eservices Online Provider Portal Provider Resources/Self Service Tools o Secure echat o Tools and Calculators o Social Media o Updates o Hospice Basics Modules How to Register The schedule of workshops is available on the Event Registration Portal under the Learning and Education section of the Palmetto GBA Home Health and Hospice webpage ( The state associations are sponsoring the workshops. Please select the link for the date of the workshop you want to attend and that will take you directly to the Association s registration page /2017

22 PROVIDER ENROLLMMENT INFORMATION Provider Enrollment Revalidation Cycle 2 MLN Matters Number: SE1605 Revised Related Change Request (CR) #: N/A Related CR Release Date: N/A Effective Date: N/A Related CR Transmittal #: N/A Implementation Date: N/A Note: This article was revised on April 10, 2017, to correct the table on page 6. The last row should have stated the date as November 29 December 14, All other information is unchanged. Provider Types Affected This Medicare Learning Network (MLN) Matters Special Edition Article is intended for all providers and suppliers who are enrolled in Medicare and required to revalidate through their Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs (HH&H MACs), Medicare Carriers, Fiscal Intermediaries, and the National Supplier Clearinghouse (NSC)). These contractors are collectively referred to as MACs in this article. Provider Action Needed STOP Impact to You Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers/suppliers to revalidate their Medicare enrollment information under new enrollment screening criteria. The Centers for Medicare & Medicaid Services (CMS) has completed its initial round of revalidations and will be resuming regular revalidation cycles in accordance with 42 CFR In an effort to streamline the revalidation process and reduce provider/supplier burden, CMS has implemented several revalidation processing improvements that are captured within this article. CAUTION What You Need to Know Special Note: The Medicare provider enrollment revalidation effort does not change other aspects of the enrollment process. Providers/suppliers should continue to submit changes (for example, changes of ownership, change in practice location or reassignments, final adverse action, changes in authorized or delegated officials or, any other changes) as they always have. If you also receive a request for revalidation from the MAC, respond separately to that request. GO What You Need to Do 1. Check for the provider/suppliers due for revalidation; 21 05/2017

23 2. If the provider/supplier has a due date listed, CMS encourages you to submit your revalidation within six months of your due date or when you receive notification from your MAC to revalidate. When either of these occur: Submit a revalidation application through Internet-based PECOS located at gov/pecos/login.do, the fastest and most efficient way to submit your revalidation information. Electronically sign the revalidation application and upload your supporting documentation or sign the paper certification statement and mail it along with your supporting documentation to your MAC; or Complete the appropriate CMS-855 application available at Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications. html; If applicable, pay your fee by going to and Respond to all development requests from your MAC timely to avoid a hold on your Medicare payments and possible deactivation of your Medicare billing privileges. Background Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers/suppliers to revalidate their Medicare enrollment information under new enrollment screening criteria. CMS has completed its initial round of revalidations and will be resuming regular revalidation cycles in accordance with 42 CFR This cycle of revalidation applies to those providers/suppliers that are currently and actively enrolled. What s ahead for your next Medicare enrollment revalidation? Established Due Dates for Revalidation CMS has established due dates by which the provider/supplier s revalidation application must reach the MAC in order for them to remain in compliance with Medicare s provider enrollment requirements. The due dates will generally be on the last day of a month (for example, June 30, July 31 or August 31). Submit your revalidation application to your MAC within 6 months of your due date to avoid a hold on your Medicare payments and possible deactivation of your Medicare billing privileges. Generally, this due date will remain with the provider/supplier throughout subsequent revalidation cycles. The list will be available at and will include all enrolled providers/suppliers. Those due for revalidation will display a revalidation due date, all other providers/ suppliers not up for revalidation will display a TBD (To Be Determined) in the due date field. In addition, a crosswalk to the organizations that the individual provider reassigns benefits will also be available at on the CMS website. IMPORTANT: The list identifies billing providers/suppliers only that are required to revalidate. If you are enrolled solely to order, certify, and/or prescribe via the CMS-855O application or have opted out of Medicare, you will not be asked to revalidate and will not be reflected on the list /2017

24 Due dates are established based on your last successful revalidation or initial enrollment (approximately 3 years for DME suppliers and 5 years for all other providers/suppliers). In addition, the MAC will send a revalidation notice within 2-3 months prior to your revalidation due date either by (to addresses reported on your prior applications) or regular mail (at least two of your reported addresses: correspondence, special payments and/or your primary practice address) indicating the provider/supplier s due date. Revalidation notices sent via will indicate URGENT: Medicare Provider Enrollment Revalidation Request in the subject line to differentiate from other s. If all of the s addresses on file are returned as undeliverable, your MAC will send a paper revalidation notice to at least two of your reported addresses: correspondence, special payments and/or primary practice address. NOTE: Providers/suppliers who are within 2 months of their listed due dates on MedicareRevalidation but have not received a notice from their MAC to revalidate, are encouraged to submit their revalidation application. To assist with submitting complete revalidation applications, revalidation notices for individual group members, will list the identifying information of the organizations that the individual reassigns benefits. Large Group Coordination Large groups (200+ members) accepting reassigned benefits from providers/suppliers identified on the CMS list will receive a letter from their MACs listing the providers linked to their group that are required to revalidate for the upcoming 6 month period. A spreadsheet detailing the applicable provider s Name, National Provider Identifier (NPI) and Specialty will also be provided. CMS encourages the groups to work with their practicing practitioners to ensure that the revalidation application is submitted prior to the due date. We encourage all groups to work together as only one application from each provider/supplier is required, but the provider must list all groups they are reassigning to on the revalidation application submitted for processing. MACs will have dedicated provider enrollment staff to assist in the large group revalidations. Groups with less than 200 reassignments will not receive a letter or spreadsheet from their MAC, but can utilize PECOS or the CMS list available on to determine their provider/supplier s revalidation due dates. Unsolicited Revalidation Submissions All unsolicited revalidation applications submitted more than 6 months in advance of the provider/supplier s due date will be returned. What is an unsolicited revalidation? o If you are not due for revalidation in the current 6 month period, your due date will be listed as TBD (To Be Determined). This means that you do not yet have a due date for revalidation. Please do not submit a revalidation application if there is NOT a listed due date /2017

25 o Any off-cycle or ad hoc revalidations specifically requested by CMS or the MAC are not considered unsolicited revalidations. If your intention is to submit a change to your provider enrollment record, you must submit a change of information application using the appropriate CMS-855 form. Submitting Your Revalidation Application IMPORTANT: Each provider/supplier is required to revalidate their entire Medicare enrollment record. A provider/supplier s enrollment record includes information such as the provider s individual practice locations and every group that benefits are reassigned (that is, the group submits claims and receives payments directly for services provided). This means the provider/supplier is recertifying and revalidating all of the information in the enrollment record, including all assigned NPIs and Provider Transaction Access Numbers (PTANs). If you are an individual who reassigns benefits to more than one group or entity, you must include all organizations to which you reassign your benefits on one revalidation application. If you have someone else completing your revalidation application for you, encourage coordination with all entities to which you reassign benefits to ensure your reassignments remain intact. The fastest and most efficient way to submit your revalidation information is by using the Internetbased PECOS. To revalidate via the Internet-based PECOS, go to PECOS allows you to review information currently on file and update and submit your revalidation via the Internet. Once completed, YOU MUST electronically sign the revalidation application and upload any supporting documents or print, sign, date, and mail the paper certification statement along with all required supporting documentation to your appropriate MAC IMMEDIATELY. PECOS ensures accurate and timelier processing of all types of enrollment applications, including revalidation applications. It provides a far superior alternative to the antiquated paper application process. To locate the paper enrollment applications, refer to Enrollment-and-Certification/MedicareProviderSupEnroll/EnrollmentApplications.html on the CMS website. Getting Access to PECOS: To use PECOS, you must get approved to access the system with the proper credentials which are obtained through the Identity and Access Management System, commonly referred to as I&A. The I&A system ensures you are properly set up to submit PECOS applications. Once you have established an I&A account you can then use PECOS to submit your revalidation application as well as other enrollment application submissions /2017

26 To learn more about establishing an I&A account or to verify your ability to submit applications using PECOS, please refer to MLN/MLNProducts/Downloads/MedEnroll_PECOS_PhysNonPhys_FactSheet_ICN pdf. If you have questions regarding filling out your application via PECOS, please contact the MAC that sent you the revalidation notice. You may also find a list of MAC s at Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/contact_list.pdf. For questions about accessing PECOS (such as login, forgot username/password) or I&A, contact the External User Services (EUS) help desk at or at EUSSupport@cgi.com. Deactivations Due to Non-Response to Revalidation or Development Requests It is important that you submit a complete revalidation application by your requested due date and you respond to all development requests from your MACs timely. Failure to submit a complete revalidation application or respond timely to development requests will result in possible deactivation of your Medicare enrollment. If your application is received substantially after the due date, or if you provide additional requested information substantially after the due date (including an allotted time period for US or other mail receipt) your provider enrollment record may be deactivated. Providers/suppliers deactivated will be required to submit a new full and complete application in order to reestablish their provider enrollment record and related Medicare billing privileges. The provider/supplier will maintain their original PTAN; however, an interruption in billing will occur during the period of deactivation resulting in a gap in coverage. NOTE: The reactivation date after a period of deactivation will be based on the receipt date of the new full and complete application. Retroactive billing privileges back to the period of deactivation will not be granted. Services provided to Medicare patients during the period between deactivation and reactivation are the provider s liability. Revalidation Timeline and Example Providers/suppliers may use the following table /chart as a guide for the sequence of events through the revalidation progression. Action Timeframe Example Revalidation list posted Approximately 6 months prior to March 30, 2017 due date Issue large group notifications Approximately 6 months prior to March 30, 2017 due date MAC sends /letter days prior to due date July 2-17, 2017 notification MAC sends letter for days prior to due date July 2-17, 2017 undeliverable s Revalidation due date September 30, /2017

27 Apply payment hold/issue Within 25 days after due date October 25, 2017 reminder letter (group members) Deactivate days after due date November 29 December 14, 2017 Deactivations Due to Non-Billing Providers/suppliers that have not billed Medicare for the previous 12 consecutive months will have their Medicare billing privileges deactivated in accordance with 42 CFR The effective date of deactivation will be 5 days from the date of the corresponding deactivation letter issued by the MACs notifying the providers/suppliers of the deactivation action. Providers/suppliers who Medicare billing privileges are deactivated will be required to submit a new full and complete application in order to reestablish their provider enrollment record and related Medicare billing privileges. The provider/supplier will maintain their original PTAN; however, an interruption in billing will occur during the period of deactivation resulting in a gap in coverage. Application Fees Institutional providers of medical or other items or services and suppliers are required to submit an application fee for revalidations. The application fee is $ for Calendar Year (CY) CMS has defined institutional provider to mean any provider or supplier that submits an application via PECOS or a paper Medicare enrollment application using the CMS-855A, CMS-855B (except physician and nonphysician practitioner organizations), or CMS-855S forms. All institutional providers (that is, all providers except physicians, non-physicians practitioners, physician group practices and non-physician practitioner group practices) and suppliers who respond to a revalidation request must submit the 2017 enrollment fee (reference 42 CFR ) with their revalidation application. You may submit your fee by ACH debit, or credit card. To pay your application fee, go to cms.hhs.gov/pecos/feepaymentwelcome.do and submit payment as directed. A confirmation screen will display indicating that payment was successfully made. This confirmation screen is your receipt and you should print it for your records. CMS strongly recommends that you include this receipt with your uploaded documents on PECOS or mail it to the MAC along with the Certification Statement for the enrollment application. CMS will notify the MAC that the application fee has been paid. Revalidations are processed only when fees have cleared. SUMMARY: CMS will post the revalidation due dates for the upcoming revalidation cycle on MedicareRevalidation for all providers/suppliers. This list will be refreshed periodically. Check this list regularly for updates. MACs will continue to send revalidation notices (either by or mail) within 2-3 months prior to your revalidation due date. When responding to revalidation requests, be sure to revalidate your entire Medicare enrollment record, including all reassignment and practice locations. If you have multiple reassignments/billing structures, you must coordinate the revalidation application submission with all parties /2017

28 If a revalidation application is received but incomplete, the MACs will develop for the missing information. If the missing information is not received within 30 days of the request, the MACs will deactivate the provider/supplier s billing privileges. If a revalidation application is not received by the due date, the MAC may place a hold on your Medicare payments and deactivate your Medicare billing privileges. If the provider/supplier has not billed Medicare for the previous 12 consecutive months, the MAC will deactivate their Medicare billing privileges. If billing privileges are deactivated, a reactivation will result in the same PTAN but an interruption in billing during the period of deactivation. This will result in a gap in coverage. If the revalidation application is approved, the provider/supplier will be revalidated and no further action is needed. Additional Information To find out whether a provider/supplier has been mailed a revalidation notice go to MedicareRevalidation on the CMS website. A sample revalidation letter is available at Certification/MedicareProviderSupEnroll/downloads/SampleRevalidationLetter.pdf on the CMS website. A revalidation checklist is available at Certification/MedicareProviderSupEnroll/Revalidations.html on the CMS website. For more information about the enrollment process and required fees, refer to MLN Matters Article MM7350, which is available at Network-MLN/MLNMattersArticles/downloads/MM7350.pdf on the CMS website. For more information about the application fee payment process, refer to MLN Matters Article SE1130, which is available at MLNMattersArticles/downloads/SE1130.pdf on the CMS website. The MLN fact sheet titled The Basics of Internet-based Provider Enrollment, Chain and Ownership System (PECOS) for Provider and Supplier Organizations is designed to provide education to provider and supplier organizations on how to use Internet-based PECOS to enroll in the Medicare Program and is available at downloads/medenroll_pecos_providersup_factsheet_icn pdf on the CMS website. To access PECOS, your Authorized Official must register with the PECOS Identification and Authentication system. To register for the first time go to do?transferreason=createlogin to create an account. For additional information about the enrollment process and Internet-based PECOS, please visit the Medicare Provider-Supplier Enrollment webpage at /2017

29 If you have questions, contact your MAC. Medicare provider enrollment contact information for each State can be found at MedicareProviderSupEnroll/Downloads/contact_list.pdf. Document History Date of Change April 10, 2017 March 15, 2017 February 22, 2016 Description The article was revised to correct the table on page 6. The last row should have stated the date as November 29 December 14, The updated article revised the table on page 6 and added additional information after that table. Initial article released This advisory should be shared with all health care practitioners and managerial members of the provider/ supplier staff. Medicare Advisories are available at no cost from the Palmetto GBA website at www. PalmettoGBA.com/hhh. Address Changes Have you changed your address or other significant information recently? To update this information, please complete and submit a CMS 855A form. The most efficient way to submit your information is by Internet-based Provider Enrollment, Chain and Ownership System (PECOS). To make a change in your Medicare enrollment information via the Internet-based PECOS, go to on the CMS website. To obtain the hard copy form plus information on how to complete and submit it, visit the Palmetto GBA website ( /2017

30 TOOLS THAT YOU CAN USE Medicare Credit Balance Report Module This interactive module provides assistance with completing the Medicare Credit Balance Report (CMS- 838). A credit balance is an improper or excess payment made to a provider as a result of patient billing or claims processing errors. Providers must submit this report quarterly. Failure to submit the report, within 30 days of each quarter end, may result in suspension of payments and your eligibility to participate in the Medicare program. To access the Medicare Credit Balance Report Module on the Palmetto GBA website, select the link below: /2017