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MA Plan Enrollment Begins During a Home Health Episode/Period of Care

When a Medicare beneficiary elects an MA plan during an episode/period of care, the episode/period of care will end and be proportionally paid according to its shortened length (a partial episode payment (PEP) adjustment). The MA plan becomes the primary payer effective with the MA plan enrollment date. CGS cannot make payments for dates of service falling within a beneficiary's enrollment in an MA plan, unless the beneficiary has also elected the Medicare hospice benefit.

If the home health agency (HHA) is aware that a beneficiary has enrolled in a MA plan as of a certain date, they should submit their final claim (3X9 type of bill) for the shortened episode with a "TO" date that reflects the last date the beneficiary had coverage under traditional Medicare, and prior to the MA plan enrollment date. The claim should be coded with patient status code "06" in the "STAT" field (FL 17). If the claim contains line item dates of service (LIDOS) that fall after the enrollment date of the MA plan, the claim will reject (FISS status/location R B9997) with reason code 7CS21. Claims that reject with this reason code will need to be resubmitted without the overlapping dates of service.

Updated: 12.23.19


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