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Demand Denials (Condition Code 20)

The revised Home Health Beneficiary Notice of Non-coverage (HHABN), Form CMS-R-296, is now available, and Home Health Agencies (HHAs) may begin using this notice immediately.

Mandatory use of the revised HHABN began on April 1, 2011. All HHABNs with the expiration date of 08/31/09 that are issued on and after April 1, 2011 will be considered invalid.

Home Health Advance Beneficiary Notice or (HHABN) has been required since 2002 to inform beneficiaries about possible non-covered charges when limitation of liability applies.

Demand billing is a procedure through which beneficiaries can request Medicare payment for services that:

  1. Their HHAs advised them were not medically reasonable and necessary, or that
  2. They failed to meet the homebound, intermittent or noncustodial care requirements, and therefore would not be reimbursed if billed.

NOTE: If an HHABN was provided to the beneficiary as a result that the services did not the Medicare covered benefit definition (i.e. routine foot care) or are custodial in nature (housekeeping or home health aide services) and the beneficiary has authorized billing Medicare, the HHA should submit a no-pay bill using condition code 21.

The HHA must inform the beneficiary of their decision with a Home Health Advance Beneficiary Notice (HHABN), which also must be signed by the beneficiary or appropriate representative before any services are provided. The HHABN provides the beneficiary with the option to have a demand denial (condition code 20) submitted to Medicare for review. The HHA must comply with the beneficiary's request to submit a demand bill (condition code 20).

Demand denials must be submitted promptly once the last billable service is provided and the physician's signature has been obtained for all orders. Beneficiaries may pay out of pocket or third party payers may cover the services in question. All demand denials will be subject to medical review through the additional development request (ADR) process.

If medical review determines some or all of the disputed services are covered, the HHA must refund any previously collected funds.

If medical review upholds the HHA's decision that the services were not coverable, the HHA keeps the funds collected from the beneficiary. However, if the Regional Home Health Intermediary (RHHI) determines the HHABN notification was not properly executed, or some other factor changed liability for payment of the disputed services to the HHA, the HHA must refund any funds collected.

Billing Requirements

In demand denial situations, a RAP is required to be billed as usual;

  • do not submit the RAP with condition code 20.
  • Submit condition code of 20 on the final claim.
  • The RAP will process and pay the appropriate percentage payment and the episode will be posted to the beneficiary eligibility record (ELGA/ELGH).
  • Demand denial (condition code 20) information is submitted on HH PPS claims with a TOB (type of bill) 329 and includes all the required information including all visit-specific detail for the entire HH PPS episode.
  • Please note that TOB 3X0 is no longer valid for demand bills where condition code 20 is used.

The following information must also be provided on a demand bill.

  • Condition code 20
  • Charges for services in dispute shown as covered and non-covered
  • Remarks indicating the reason for the demand denial (condition code 20)
  • If there are covered and non-covered services during the same episode, bill all services on one claim.

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