November 6, 2019
Open Forum Ask the Contractor Teleconference (ACT) October 10, 2019
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- Why is the decision for re-openings/re-considerations not listed on the message tab? When we search with the W# it states – completed, but it doesn't give the decision. Also, is there a way to make the decision letters accessible on the message screen? We can get letters, why can't we also have access to the appeal/re-opening letters in the same place?
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You are correct. The W# allows you to obtain a general status (i.e., Processing, Complete) of the request. Requests for Reopening are adjusted and can be found on your Remittance Advice (RA). For Redeterminations, if the appeal is fully favorable, you will find the adjustment also on your RA, so no letter is generated. If the Redetermination decision is partially-favorable or unfavorable, we will issue a letter of explanation, which will be delivered to your Messages inbox. If you do not have access to this information, please check with your office Provider Administrator for assistance.
Reference:
- Medicare Claims Processing Manual, Pub 100-04, Chapter 34 – Reopening and Revision of Claim Determinations and Decisions – Section 10.8 – Notice of a Revised Determination or Decision
- Attention myCGS Administrators and Users: Update Opt In/Opt Out to Green Mail!
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- Is there a way to link any ADR letters &/or appeal responses to the claim itself? So we can go to the claim screen and when we search to see status, any letter that is related with the claim is available by a link?
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Currently, ADR letters are linked to the claim. If the claim has been selected for medical review, you can find a copy of the ADR letter on your MR Dashboard. If an ADR was sent from our Claims department, a copy of the ADR is available in your Claims tab. Your suggestion to have these letters and responses to appeal requests is a good one. We will share this suggestion with the myCGS Development Team for evaluation.
Reference:
- Retrieving Redetermination Letters from myCGS
- Reviewing ADR Letters from Medical Reviews Dashboard in myCGS
- myCGS Claim Status Enhancements
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- Is there an event for Part B providers in respect to billing when the pt is hospice? When to bill to CGS when to bill to the hospice etc…?
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There are no current events at this time scheduled for Part B Hospice Education, however we are always open for education request and have listed this request with our 2020 education training. Please continue to check our Calendar of Events for future dates and time of upcoming events.
Reference:
- Hospice Regulations and Notices
- CGS Part B Modifier Finder Tool
HCPCS modifier GW—Service not related to the Hospice Patient's Terminal Condition
HCPCS modifier GV—Attending Physician not employed or Paid under Arrangement by the Patient's Hospice Provider - myCGS Web Portal
- myCGS User Manual Eligibility, Hospice Benefit Periods
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- It's been brought to my attention during conversations with CGS customer service… the MBI# can change… how/why/when? I had a pt we had 2 MBI#s for and they BOTH worked on myCGS…
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There are times when Social Security may change the Health Insurance Claim Number (HICN) / Medicare Beneficiary Identifier (MBI). This can happen if benefits are to be provided under a spouse, or they initially enrolled under their spouse and the spouse's status changes. For example, the spouse is now deceased or the beneficiary now has enough quarters to carry their own Medicare enrollment. With the new MBI, each beneficiary will be assigned one MBI, and this will appear with the most current HICN on the crosswalk files.
Reference:
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- Changing MBI# – will myCGS alert us if we log in with an expired MBI#?
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No, myCGS will not release an alert when the MBI has expired. It will be your responsibility to verify eligibility before submitting your claims to Medicare or the Medicare Advantage Plan.
Reference:
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- I sent the DDE Recertification in July 2019. I do have a fax confirmation. Is there a way to verify you've received it?
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To verify if we've received your DDE Recertification form, you may contact our Electronic Data Interchange department.
- Part A – 1.866.590.6703, option 2
- Part B – 1.866.276.9558, option 2
- Home Health and Hospice – 1.877.299.4500, option 2
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- Hospice MSW visits for last week of care. We are not getting an add-on payment for that visit. Is CGS aware of a claims processing issue where hospice claims are denying with denial code U5200 – CMS records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made. We've had several Sept 2019 claims deny with this reason code for patients that have active coverage.
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CGS was notified that beneficiary eligibility dates were missing due to issues at the Enrollment Database (EDB). The entitlement data sent for new and/or updated beneficiaries processed at the Common Working File (CWF) between October 7, 2019 and October 9, 2019 posted with blank/zero entitlement dates causing claims to reject with reason code U5200. If you have claims that rejected with U5200, please resubmit for processing.
CGS notified providers of this issue in a listserv message dated October 9th and October 15th. CGS also updated the Claims Processing Issues web pages with this information. If you are not registered to receive important message from CGS, consider joining the CGS Listserv Notification Service to stay informed.
Reference:
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- Is there any way to verify that my PTAN Recertification form was received?
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When it is your turn to Revalidate your enrollment in Medicare and you submit a completed CMS-855 application, a confirmation is sent via email or mail acknowledging receipt. This acknowledgement letter will include a Reference Number, which can be used to check the status of your application.
If you are referring to the Annual DDE PPTN Recertification, you may contact our Electronic Data Interchange department to check on the status of your Recertification form.
- Part A – 1.866.590.6703, option 2
- Part B – 1.866.276.9558, option 2
- Home Health and Hospice – 1.877.299.4500, option 2
Reference:
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- I pre-submitted this and didn't get a response. Will CMS be accepting NPs signature for certification of home health in Maryland, as state law has made NPs independent practitioners with no requirement for physician supervision agreements?
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The Centers for Medicare & Medicaid Services (CMS) recently issued the MLN Matters article, MM11330, Home Health Orders for Nurse Practitioners under the Maryland Total Cost of Care (TCOC) Model. Although, under Maryland law, a nurse practitioner can provide primary care services, under Medicare rules a beneficiary must be under the care of a physician in order to receive home health care services. Therefore, currently, Medicare pays for home health services only if a physician certifies the beneficiary's eligibility for the home health benefit – not a nurse practitioner. Refer to the MM11330 article for additional information.
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- How do we bill when a resident is cut from skilled care but remains in the building and is picked up skilled within 30 days?
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Example: A resident is admitted on 2.12.19 skilled and then is cut from skilled care on 3.11.19 and remained in the facility as private pay. Then was picked back up as skilled on 3.28.19. Would our claim for March have an admit date of 2.12.19 or 3.28.19 with occurrence span code 78 and condition code 57? Does the no pay claim for 3.12.19 – 3.27.19 need to be billed before we can submit the claim beginning on 3.28.19?
A patient is deemed not to have been discharged if the time between SNF discharge and readmission to the same or another SNF is within 30 days. When a discharge bill has been sent and the patient is readmitted to the SNF within 30 days, the SNF must submit another bill, which shows the current admission date with condition code 57 to indicate the patient previously received Medicare covered SNF care within 30 days of the current SNF admission and occurrence span code 70 to indicate the qualifying stay dates for a hospital stay of at least 3 days which qualifies the patient for payment of the SNF level of care services billed on the claim. Since SNF claims must be submitted in sequence (i.e., if the claim for prior dates of service is not finalized, a claim for subsequent dates of service will RTP), the skilled claim for 2.12.19-3.11.19 must be submitted and processed. Then, the no pay claim for 3.12.19-3.27.19 must be submitted and processed before the skilled claim beginning on 3.28.19 may be submitted.
Reference:
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- Our Part A claims in the CJR model skilled nursing 3 day rule waiver are not going through even when demonstration code 75 is in the appropriate box, which is supposed to bypass the qualifying stay rule. I have called and the rep has verified the hospital claim is on file and the code is on our claim. Yet, the claims still continue to deny. Is there an issue with these types of claims?
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CGS is not aware of a claims processing issue related to this type of claim. Claim example(s) are necessary to determine if there is a claim submission error or a claims processing error.
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- When doing appeals, can we send documentation from a month prior and a month after claim month in review to state our case of eli?
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Any documentation that supports medical necessity of the services included in the redetermination request may be submitted, including documentation for dates of service not included in the request.
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- Can I submit my claims through myCGS?
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Yes, Part B providers can submit claims electronically through myCGS in addition to Medicare Secondary Payer Claims.
Reference:
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- How can I tell if my claims have been received by CGS?
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There are a few ways to do this.
- Call the CGS Interactive Voice Response (IVR) system. The IVR can confirm claim status, and whether the claim is in process, on the payment floor, or paid/denied. The IVR number is:
- Home Health and Hospice: 1.877.220.6289
- Part A: 1.866.289.6501
- Part B: 1-866-290-4036
- Use CGS's web portal, myCGS, to confirm this information (you must be a registered user to use myCGS).
- If claims are electronically submitted from your office, your clearinghouse/submission software may have information or a confirmation of claims being electronically submitted.
- Call the CGS Interactive Voice Response (IVR) system. The IVR can confirm claim status, and whether the claim is in process, on the payment floor, or paid/denied. The IVR number is:
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- How can I request a Provider Outreach & Education (POE) representative to come present Medicare Updates at our local meeting or conference?
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If you would like to request a CGS POE Representative for a meeting in your area, please e-mail your request to:
- Home Health and Hospice: J15_HHH_Education@cgsadmin.com
- Part A: J15_PartA_Education@cgsadmin.com
- Part B: J15_PartB_Education@cgsadmin.com
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- Do the TPE Audits have a point at which there will be a pause ? Is this expected to continue indefinitely or is there a plan to discontinue?
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CGS is not aware of plans to pause or discontinue TPE at this time. TPE will continue indefinitely unless directed by CMS.
Reference:
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- PDGM is the most concern for discussion for me as the intake clerk.
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I'm concerned about when we receive the referral. If they referring diagnosis is not in the grouping model, do we wait for the physician to rewrite the order? Would the assessing clinician put the primary diagnosis on the plan of care, for the more specific diagnosis, that pertains to the referring diagnosis?
This should be an internal agency issue on how they handle this. An RN or Therapist can't diagnosis per scope of practice.
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- Maryland does not require physician supervision of nurse practitioners. Will CMS be accepting nurse practitioners' signatures to certify the need for home health?
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Nurse practitioners or physician assistants are not allowed to sign certifications. Under Medicare rules a beneficiary must be under the care of a physician in order to receive home health care services. However, the Centers for Medicare & Medicaid Services (CMS) recently issued the MLN Matters article, MM11330, Home Health Orders for Nurse Practitioners under the Maryland Total Cost of Care (TCOC) Model. Change Request 11330 enables all Medicare-enrolled nurse practitioners in Maryland to certify home health services for Medicare beneficiaries as part of the Maryland Total Cost of Care (TCOC) Model. Refer to the MM11330 article for additional information.
Reference:
- Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7 – Home Health Services; Section 30.5.1
- MM11330, Home Health Orders for Nurse Practitioners under the Maryland Total Cost of Care (TCOC) Model
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- Currently we do a chart review after each certification period. If we find an order inadvertently did not get queued and sent then we wait to final bill until the order is signed and returned. With PDGM the billing moves to 30 day periods, recert/episode remains at 60 days. If we find on recertification review (every 60 days) that an order was missed in the first 30 day period that has already been billed do we need to return payment for that 30 day period, re-RAP and then final bill when the order is received?
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Providers would need to verify they have the orders for the 30 day period they are billing. CGS encourages providers to have a strong internal process for order verification. Conditions for billing the RAP are to have at least verbal orders received and documented and this is not changing with PDGM.
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- Scenario: Missing narrative summary for Benefit Period 2 or lack of chosen attending physician certification due to unable to obtain one.
Question: Other than the case of a missing F2F, under what circumstances would a beneficiary need to be discharged and readmitted related to the cert/recertification process?
1. i.e.: if a narrative summary was missing for benefit period 2 cert but is present for benefit period 3, do those months between BP2 and 3 become non-bill or does the hospice need to administratively discharge and readmit?
2. Claim is billed but then noticed that there is no signed attending cert and unable to obtain one.
3. Are there other circumstances?-
It would be an internal agency decision on how they choose to handle the scenario. As a MAC we can't tell them when to discharge and readmit.
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- When the HIC# changes, the system usually refers you to the new HIC# for the patient. If the MBI# changes, will the system direct us to the new MBI# as the HIC# did?
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The provider who posed the question uses Ability, so we encourage providers to check with their vendors regarding similar concerns and their readiness with the Medicare Beneficiary Identifier (MBI) Transition. However, the MBI should function as the HICN has in the past.
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- The system currently pulls up the correct HIC# for you if most of the information is correct. It shows what you keyed, invalid, and the correct HIC#. Will the system give the correct MBI if the other information is correct?
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The provider who posed the question uses Ability, so we encourage providers to check with their vendors regarding similar concerns and their readiness with the Medicare Beneficiary Identifier (MBI) Transition.
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- I was told ALL HIC#'s will change over to MBI's for 01.01.2020. With all the Hospice issues we are having on our claims (SIA payments due, tier level issues, etc.), if some of these are not corrected until after the first of the year and the patient is now deceased with NO MBI#, How will we get these worked? I checked to see if one of our patient's now deceased had an MBI# through the web portal and the system stated the information was invalid. I am understanding this to mean they have no MBI#.
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Adjustments and appeals may continue to be submitted with the HICN after the transition period.
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- If the name is spelled incorrectly and the MBI# is correct, will the system give the correct name spelling as the system currently does for HIC#'s? (suffix's, spaces, additional letters, etc..)
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The provider who posed the question uses Ability, so we encourage providers to check with their vendors regarding similar concerns. Be sure to verify eligibility using your system of choice.
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- Upon the system update in January 2020 using MBI only, if we adjust a claim with a HIC# will the system update this to MBI, or do we change this to the MBI before submitting our adjustment through DDE?
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Adjustments are one of the limited exceptions where providers may continue to use the HICN after the transition period.
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- When will the Hospice Transfer issue with tier payments be resolved and will providers have to manually adjust the claims for the correct payments?
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We apologize for this inconvenience. CMS is working to resolve.
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- The CWF is indicated to be discontinued in the future. We continue to have issues where HETS only returns Hospice benefit periods from the 4 previous years. We continue to verify eligibility in CWF and find that the benefit periods are reflected correctly. Why can't HETS provide the same information? We will have missed F2F and benefit period issues if this is not resolved and CWF is retired.
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Change Request 11277 was to be implemented October 7, 2019, and should resolve most of these discrepancies. If you continue to encounter problems, please contact our PCC at 1.877.299.4500, Option 1.
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- We recently received an EFT payment/remittance that had several patients with SIA visits paid twice. When calling the PCC, they indicated they do not see that the charges were over paid. We can clearly see this on the remittance and were paid more than we billed. Is this an issue that will be resolved by CGS or will we have to indicate this on the credit balance report, also why would the PCC see conflicting information?
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The Provider Outreach and Education Team is not aware of this issue. However, anytime you're receiving conflicting information, you may request to have your call escalated or request a call back from a Tier 2 or supervisor. Please contact our Provider Contact Center again for further assistance.
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- What are the billing days for PDGM, days from SOC? Prior to billing what should be present in order to bill the first 30?
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Home health agencies (HHAs) will need to submit a RAP at the beginning of each 30-day period and a final claim at the end of each 30-day period. Before submitting the final claim, the HHA should ensure the OASIS assessment is completed and submitted to the iQIES system and the Request for Anticipated Payment (RAP) is submitted. Refer to the CGS Home Heath Patient-Driven Groupings Model (PDGM) Web page for a CGS Overview.
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- How are coding conventions taken into account when determining if a F2F encounter note is related to the primary reason for care?
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We are not allowed to give advice on coding concerns.
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- Since the referring dx has to be in certain models, will physicians need to rewrite orders. ex: shortness of breath to CHF?
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The physician should show the diagnosis, rather than symptoms.
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- Under the therapy maintenance is therapy assistance now going to be allowed to do maintenance programs under PDGM Rule?
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CMS Proposed Rule CY2020 states, "It would be appropriate to allow therapist assistants to perform maintenance therapy services under a maintenance program established by a qualified therapist under the home health benefit, if acting within the therapy scope of practice defined by state licensure laws. The qualified therapist would still be responsible for the initial assessment; plan of care; maintenance program development and modifications; and reassessment every 30 days, in addition to supervising the services provided by the therapist assistant." However, the CMS Final Rule CY 2020 has not yet been released.
Reference:
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- If an 855I is submitted with changes to an address, why is it not relayed to all departments within the MAC? example reimbursement
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Hospice addresses are not updated via the 855I, they are updated via the 855A. Address updates are forwarded to our internal reimbursement area. We'd need to see specific examples.
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- How will CGS Medical Review be reviewing whether or not Clinical Grouping has changed for subsequent 30 day billing periods?
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CGS Medical Review will review for documentation to support the change in Clinical Grouping. An Other Follow-Up Assessment is not required.
Reference:
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- On Jan 1, 2020, will Home Health 30 day period claims need to be billed sequentially?
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There is no sequential submission requirement now, and there will not be any sequential submission requirement under PDGM.
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