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Part IV - Instructions for Regional Home Health Intermediaries (RHHIs) and Hospices on Advance Beneficiary Notice (ABN) Standards for Certain Hospice Claims
Section IV.1. Incorporation by Reference of Part I of this PM.--Hospices and Regional Home Health Intermediaries (RHHIs) processing hospice claims must follow the general requirements for ABNs as they are enunciated in Part I of this PM. Insofar as those requirements are specifically applicable to two types of potential hospice claims denials, hospices and RHHIs must follow the instructions in Part IV of this PM.
Section IV.2. Denial Situations that Call for ABNs.--There are two situations in which hospice services may be denied, for which an ABN is appropriate:
- Due to ineligibility (the beneficiary is not “terminally ill” within the statutory definition in §1861(dd)(3)(A) of the Act, per §1879(g)(2) of the Act); and
- Because a level of care is determined inappropriate for the hospice patient (under §1862(a)(1) of the Act).
Section IV.3. Acceptable ABN Language.--Hospices are required to give an ABN to Medicare beneficiaries when the hospice believes that Medicare will deny payment on one of the bases listed in §IV.2. When preparing such an ABN, the hospice must use the following approved language for filling in the “Items or Services” and “Because” boxes on the CMS-R-131-G form, as follows:
- Ineligibility:
Box 1: Item or Services: “The Medicare hospice benefit.”
Box 2: Because: “We have determined that you are not eligible under Medicare rules for certification as having a terminal prognosis as defined in the law.”
- Level of Care:
Box 1: Item or Services: “The hospice General Inpatient Care level of care.” OR “the hospice Continuous Home Care level of care.”
Box 2: Because: “We have determined that you do not require this level of service.”
Section IV.4. Demand Bills.--A demand bill is a complete, processable claim which must be submitted promptly to Medicare by the hospice at the timely request of the beneficiary, the beneficiary's representative, or in the case of a beneficiary dually entitled to Medicare and Medicaid, a state as the beneficiary's subrogee. A demand bill is requested usually, but not necessarily, pursuant to notification of the beneficiary (or representative or subrogee) of the fact that the hospice expects Medicare to deny payment of the claim. When the beneficiary (or representative or subrogee) selects an option on an advance beneficiary notice that includes a request that a claim be submitted to Medicare, no further demand is necessary; a demand bill must be submitted.
A. The hospice always must submit a claim, billing as covered, for an initial determination when it gave an ABN on the basis of the likelihood of denial of payment. On such a claim, the hospice must enter “occurrence” code 32 on the UB-92 in one of the fields numbered 32 through 35. This code indicates the date the hospice gave the ABN to the beneficiary. It is the occurrence code 32, and not any “condition” code, that indicates to the RHHI that an ABN has been issued. Occurrence code 32 is mandatory; it must be used anytime an ABN was obtained.
B. A hospice that has obtained a signed ABN (form CMS-R-131) shall not enter condition code 20 (the demand bill condition code) on the UB-92. Condition code 20 is never to be used when an ABN (form CMS-R-131) has been obtained; only occurrence code 32 shall be used. The RHHI must not routinely deny payment for hospice services billed with occurrence code 32. The provision of an ABN by the hospice only represents the hospice’s assessment that Medicare will deny payment. The RHHI must make its initial determination on the usual bases, without being influenced by occurrence code 32 being on the claim. After the RHHI has denied payment on a claim, it must take into account the presence of occurrence code 32 in determining the liability of the beneficiary and the hospice with respect to those specific service(s) for which the ABN was given and signed. Occurrence code 32 removes any need for hospices to routinely submit copies of ABNs to the RHHI which does not need to review actual ABNs unless there is a complaint or allegation of improper use of the ABN which it must investigate. When an occurrence code 32 is included on a claim, the RHHI shall not routinely require the hospice to also submit a copy of the ABN.
C. The hospice may submit claims, for initial determination, for statutorily excluded services, if the beneficiary requests it. On claims for statutorily excluded services, the hospice should enter a condition code 21 on the UB-92 in one of the fields numbered 24 through 30 to indicate that it realizes that the furnished services are excluded, but that it is requesting a denial notice from Medicare in order to bill Medicaid or other insurers. This is also known as a “no-pay” claim. The RHHI must handle such a claim in the same manner as it handles all other claims with condition code 21 entered on them. |
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