DIRCECT FILING OF MCR HMO-HOSPICE CLAIMS TO MEDICARE

DESCRIPTION OF THE ISSUE

Medicare HMO Hospice Claims were billed incorrectly to the HMO plans directly.  We are suppose to bill the claims to Medicare.  Hence the claims were denied as “Bill Medicare Directly”

CONCEPT

Per 2010 Hospice Regulatory “The hospice, not the HMO, is responsible for managing the patient's hospice plan of care across all levels and sites of care. The Medicare-certified hospice bills Medicare, not the HMO, for the Medicare patient's hospice care”

SOLUTION

On receiving denials we analyzed 2010 Hospice Regulatory Act and started refiling denied claims towards Medicare directly. 

Hospice Claim Filing

• Must file claims electronically or bill on a UB-04 claim form.
• Must use appropriate revenue codes for services rendered. When billing revenue codes, use:
• 0651 – Routine Home Hospice (Intermittent)
• 0652 – Continuous Home Hospice
• 0655 – Inpatient Respite Care
• 0656 – Inpatient Hospice Services
• Must preauthorize before services are rendered.
• Must itemize all services and bill standard retail rates.
• Inpatient services and home services cannot be billed together on the same claim.
• Must use NPI in field 56.
• Type of bill must be 811 if non-hospital based, or 821 if hospital based (form locator 4).
• Form locators 12 (Source of Admission) and 17 (Patient Status) are required fields. If either field is blank, the claim will be returned for this information (refer to your UB-04 manual for the correct codes).
• Form locator 63 must be completed with a referral number and a precertification number from the HMO.
• All non-routine items must be supplied by the appropriate provider specialty. For example: A special hospital bed or customized
wheelchair must be supplied and billed by a Durable Medical Equipment (DME) provider.