ADRs Increasing

Home Care Alliance members are reporting an increase in” additional documentation requests” or ADRs from the fiscal intermediary, NHIC.  Although there does not seem to be a pattern to the diagnoses requested, the majority are LUPAs. Additionally, many are being denied after the initial review and the first appeal.  Members are encouraged to continue the appeal process if you feel your decision has merit.

The fiscal intermediaries are required to do a certain percentage of review and it is usually around 10%.  This is in addition to the TPL process which created a backlog until recently and is why they may be “catching up” to their regular workload.

Members are encouraged to contact Helen Siegel at with appeal results and/or if the number of ADRs seems unusually large.

CMS Clarifies use of HHABN for Face-to-Face Requirement

On the CMS Home Health, Hospice & DME Open Door Forum held today, March 2nd.,  staff from CMS discussed the use of the HHABN when discharging a patient because there was no F2F encounter within the required time frame.  This is a clarification of an earlier policy which said that the HHABN was not to be used in this situation.

Option BOX 2 can be used because the agency is ending services for administrative reasons such as lack of a F2F encounter.  It is a change of care notice only and there is no beneficiary liability for the care provided. Further written clarification from CMS will be forthcoming.

Regulatory Review

Expedited Review Process:

Masspro completed a series of workshops to discuss the “expedited review process,” used by home health agencies to notify Medicare beneficiaries that their Medicare services are ending. There are two separate forms and slightly different rules depending on Medicare “fee-for-service” (Notice of Medicare provider Non-Coverage) or Medicare Advantage (Notice of Medicare non-Coverage).  These forms are to be used when all Medicare services are ending for medical reasons.  If care is ending for a technical reason such as homebound, then the beneficiary is given a HHABN.  This is a recent clarification from Quest to Masspro our local QIO.

Quest is the part of the Quality Net system that QIO’s use to communicate with CMS.  QIO’s can ask Quest questions that require clarification by CMS and then publish the answers.

Is it appropriate for the HHA to issue a Notice of Medicare Provider Non-Coverage in these types of cases, and for the QIO to review?


It is not appropriate for HHAs to issue Notices of non-coverage for home-bound status; only when it is believed that the beneficiary no longer requires a skilled level of care


CMS put out a transmittal a few weeks ago to define several dates that relate to the Face-to-face Requirement.

The effective date is January 1, 2011

The implementation date that CMS contractors must have their systems ready is March 10, 2011

The enforcement date is April 1, 2011. After this date, agencies will not be reimbursed if the F2F documentation is not present in the medical record.

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NHIC Clarifies Home Health Issues

NHIC Corp, the Medicare Administrative Contractor for Jurisdiction 14 A/B/MAC, held a conference call for home health and hospice to clarify information and provide the opportunity for questions.

Change Request (CR) 6856 clarified the scope of claims editing and PECOS for home health. During Phase I (October 1, 2010-December 31, 2010), when a claim is received, the following will occur:

The RHHI will determine if an attending physician is required for the billed service; if so, that the attending physician’s NPI in on the claim. If the NPI is present,  Medicare will verify that he/she is on the national PECOS file. If the attending physician is not on the PECOS file, the claim will continue to process but a message will be included that the claim may not be paid in the future.

After January 1, 2011, if the billed service requires an attending physician and the NPI is not on the claim, the claim will not be paid.  If there is an NPI, Medicare will also verify with the national PECOS file.  If the physician is on the PECOS file but not a doctor of medicine, osteopathy, or podiatry the claim will not be paid.  CMS is still silent as to claims payment if the physician is not in PECOS or is on the “pending file” after January 1, 2011.

Providers were also reminded about CR 6960 and the timely filing requirements that were changed by the Patient Protection and Affordable care Act (PPACA).  Providers now have one year to file a Medicare claim, based on date of service.  In the case of providers that use “From” and “Through” dates, CR 7080 clarified that the “through” date is used.

Providers with questions regarding these issues or any others should contact the Customer Call Center at 866/289-0423 or for medical review-related questions, the Clinical Voice mail Box at 800/338-6101.

Check the NHIC website at to register for upcoming educational sessions including home health billing on September 15th; Clinical Medical Review Findings on November 17th; and an ACT Call (Ask-the-Contractor) on October 13th.

Revised Regulations and Billing Guide for MassHealth Hospice

MassHealth has revised their hospice regulations to reflect changes in CMS hospice rules. The new rules require hospice providers to coordinate their hospice services with the Medicaid personal care benefit, as appropriate. MassHealth members no longer have to waive their PCA services if they elect the hospice benefit.

Also, physicians signing the hospice certification statement will be required to personally compose a narrative explaining the clinical findings that support life expectancy of six months or less.

MassHealth has also revised the billing guide for the UB-04 which is posted on the MassHealth website.

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Strengthening Partnerships: Enhancing Options for Clinical Placements

In June,2009 the Foundation for Home Health and the Massachusetts Senior Care Foundation sponsored a invitation only working session for educators, home health and long term care providers. The purpose of the day long session was to promote home health and long term care as clinical placement sites for nursing students thereby increasing their awareness of geriatrics and community based programs as desirable places to work. The program was funded by a grant from the Massachusetts Department of Higher Education Nursing and Allied Health Initiative. Click here for a copy of the report.

Delays in Seasonal Flu Vaccine Distribution

We recognize that this is major inconvenience for all providers who have plans in place for administering seasonal flu vaccine.  However, please remember that the pandemic H1N1 virus is currently circulating in our communities and it is important to vaccinate as many people as possible as soon as possible with H1N1 vaccine to mitigate the impact of the H1N1 virus.   In New England, we usually don’t experience sustained transmission of seasonal flu virus strains until late fall or early winter, so there is still time to administer seasonal flu vaccine through the fall and winter.   While every flu season, and especially this one, reminds that here is very little that is predictable about influenza, CDC and other federal decision making bodies must make decisions based on the best data available at the moment.

We are all in this together, and together we will do the best job possible to protect the residents of the Commonwealth against both seasonal and H1N1 influenza.

Please see attached DPH memo based on the most recent CDC information.


DPH Emergency Regulations for Vaccine Administration

The Massachusetts Department of Public Health has promulgated and is implementing emergency regulations effective September 14, 2009 authorizing the Commissioner of Public Health to designate certain health care professionals, nursing and medical students to administer seasonal influenza and H1N1 vacine.  These regulatory amendments are part of the DPH’s planning and preparation for pandemic influenza A H1N1 this fall. Click on the following links to review the documents.

DPH Memo

Guidelines for Designated Vaccinators

Written Order Allowing Health Care Professionals and Students to Vaccinate

Attachment A: Ammendment to the Regulation 105 CMR 700.003 (H) These are DPH Regulations that ammend MGL 94 C which is the Controlled Substances Act

OASIS-C Final Version

The final version of OASIS-C is now available on the CMS website and the implementation date is January 1, 2009.   The guidance document will be available as soon as the OASIS Education Coordinator training is completed in September, 2009.  Also posted is a crosswalk from the current B1 version to this final version of “C.”

On October 26th & 27th, the Alliance is sponsoring a 2-day workshopat the Sheraton Hotel in Framingham  to assist providers in the transition process.  Registration information is now available.

Providers to Receive Letters for TPL Claims Beginning September 8, 2009

Providers should expect to see letters from “Commonwealth Medicine” representing the MassHealth TPL (Third Party Liability)  Unit on or about September 8, 2009. The letter, which will take the form of an “Initial Overpayment Notice,” will list those claims for dually-eligible beneficiaries that MassHealth has identified as requiring a Medicare determination of coverage. MassHealth is the payer of last resort and as the subrogee for these beneficiaries is requesting that you begin the demand bill process to determine if Medicare should have been billed for these services.    The claims in dispute are for Federal Fiscal Year 2008 or dates of service October 1, 2007 through September 30, 2008.

In preparation for this initiative, the Alliance in cooperation with MassHealth held 2 workshops for providers in July and August.  The process and expectations were discusses by representatives of the TPL Unit and the Provider Outreach and Education department of National Government Services reviewed the “demand bill” process.

For a copy of the TPL Powerpoint which includes an excellent timeline,  click here. For a copy of the NGS presentation discussing the demand billing process, click here

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