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Examples of Denied/Granted Exception Requests

Medicare guidelines allow for four exceptions if a hospice Notice of Election (NOE) is not filed timely. The following provides scenarios where exception requests were denied or granted by CGS. Refer to the "Requesting an Exception for an Untimely NOE" Web page for additional information.

Example #1:

Case Facts:

  • Hospice admission date 10/21/YY
  • Hospice submitted information to clearinghouse on 10/24/YY
  • Clearinghouse submitted NOE on 10/27/YY
  • NOE untimely

Review Outcome:

Exception request not granted.

Example #2:

Case Facts:

  • Hospice admission date 10/31/YY
  • Hospice submitted NOE on 11/03/YY
  • NOE went to the Return to Provider (RTP) file on 11/04/YY for invalid type of bill (TOB) 01A
  • Provider submitted new NOE on 11/24/YY
  • Provider stated they didn’t know NOE had RTPd as they check the status for NOEs with TOB 81A only

Review Outcome:

Exception not granted due to provider billing error (invalid TOB).

Exception granted for claims received on or after November 16, 2016, and if the hospice took appropriate action within 2 business days, after claim went to RTP, to make the correction. 

Note from CGS:

CGS recommends checking status of NOEs using FISS Option 12, and entering NPI and Medicare ID OR use Claims Correction Option 29 (Hospice) and remove TOB.

  • Using additional fields will narrow NOE search and can increase risk of missing errors

Example #3:

Case Facts:

  • Hospice admission date 11/11/YY
  • Hospice submitted NOE on 11/12/YY
  • NOE RTPd on 11/17/YY for U5181 (incorrect/invalid OC 27 date)
  • Provider corrected NOE on 11/18/YY

Review Outcome:

Exception not granted due to billing error (incorrect/invalid OC 27 date).

Exception granted for claims received on or after November 16, 2016, and if the hospice took appropriate action within 2 business days, after claim went to RTP, to make the correction. 

Example #4:

Case Facts:

  • Hospice admitted patient 10/09/YY
  • Hospice viewed ELGH and determined patient had open benefit period 09/16/YY – 12/14/YY and no posted revocation
  • Hospice did not submit NOE until 10/15/YY (untimely), when prior benefit period termed

Review Outcome:

Exception not granted due to provider did not submit NOE timely

Note from CGS:

If hospice had submitted NOE timely, and NOE hit U5106 (overlap of open hospice benefit period), this exception would have been granted, as the circumstance would have been beyond the hospice’s control.

Example #5:

Case Facts:

  • Provider submitted NOE for 1030YY admission on 1030YY (timely)
  • Provider realized admission date should have been 1029YY
  • Provider submitted 81D (cancel NOE) on 1128YY
  • Submitted "corrected" NOE with 1029YY admission date on 1128YY
  • Provider documentation indicates initial NOE submitted with incorrect admission date

Review Outcome:

Exception not granted due to provider billing error.

Exception granted for claims received on or after November 16, 2016, and if the hospice took appropriate action within 2 business days to submit the 81D.

Note from CGS:

The condition code D0 and occurrence code 56 can be used to correct an NOE dates. Refer to the Claim Page 01 – Correcting a Notice of Election (NOE) web page for additional information.

Example #6:

Case Facts:

  • Initial NOE submitted with admit date 10/30/YY on 11/3/YY (timely)
  • NOE "RTPd" with U5106 (NOE within previously established hospice period)
  • Hospice F9d NOE as soon as prior benefit period termed, which was beyond the 5-day timely filing period.
  • Hospice provided sufficient information in the REMARKS field (FISS Page 04) that clearly indicates all the circumstances and time frames supporting the exception request.
  • CGS confirmed NOE initially submitted timely, prior hospice’s open benefit period, and date hospice F9d NOE

Review Outcome:

Exception granted due to prior open benefit period and timely submission of NOE. This circumstance was beyond the hospice’s control.

Note from CGS:

For discharge/readmit to same hospice, timely filing of final claim/NOTR will also be considered.

Example #7:

Case Facts:

  • Initial NOE submitted with admit date 10/29/YY on 10/30/YY (timely)
  • NOE "RTPd" with 1A005 (patient middle initial invalid)
  • Provider attempted to correct NOE on 10/31, 11/03 and 11/4
  • Contacted CGS Provider Contact Center on 11/4/YY
  • CGS staff confirmed incorrect information on beneficiary file, and file was updated
  • Provider corrected NOE and F9d on 11/4
  • Hospice submitted exception request with documentation showing action taken, including CGS call log record and dated screenprints of ELGH and incorrect Beneficiary/CWF inquiry (Inquiry Option 10)

Review Outcome:

Exception granted due to documentation and prompt submission of NOE once file updated. This circumstance was beyond the hospice’s control.

Note from CGS:

If the beneficiary file contains incorrect information, providing a screenprint of FISS Inquiry Option 10 and ELGH will help justify the exception request.

Example #8:

Case Facts:

  • Hospice B admitted patient 1206YY, and identified prior hospice benefit period with TERM DATE = 0531YY (Hospice A)
  • Hospice B submitted NOE timely on 1208YY, and processed
  • On January 20, 20YY, Hospice A contacted Hospice B and requested they back out their 1206YY NOE to allow Hospice A to complete billing
  • Exception request from Hospice B provided sufficient information in the REMARKS field (FISS Page 04) that clearly indicates all the circumstances and time frames supporting the exception request.

Review Outcome:

Exception granted due to circumstances beyond Hospice B’s control.

Posted: 12.17.18

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