Sunday, June 28, 2015

Hospice denial and Actions for - Requested Records not Submitted, Face to Face Encounter Requirements Not Met, No Valid Election Statement Submitted

Auto Deny - Requested Records not Submitted
Medical records were not received in response to an Additional Documentation Request (ADR) in the required time frame; therefore, we were unable to determine medical necessity.

To prevent this denial:
Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted
Be aware of the need to submit medical records within 30 days of the ADR date. The ADR date is in the upper left corner of the ADR request.
Gather all information needed for the claim and submit it all at one time
Submit medical records as soon as the ADR is received
Attach a copy of the ADR request to each individual claim
If responding to multiple ADRs separate each response and attach a copy of the ADR to each individual set of medical records. Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost.
Do not mail packages C.O.D.; we cannot accept them
Return the medical records to the address on the ADR. Be sure to include the appropriate mail code. This ensures your responses are promptly routed to the Medical Review Department.

Face to Face Encounter Requirements Not Met
The services billed were not covered because the documentation submitted for review did not include documentation of a face to face encounter.
How to prevent this denial: 
The face to face encounter must occur no more than 30 calendar days prior to the start of the third benefit period and no more than 30 calendar days prior to every subsequent benefit period thereafter.
Specific documentation related to face to face encounter requirements must be submitted for review. This includes, but is not limited to, the following:
The hospice physician or nurse practitioner who performs the encounter must attest in writing that he or she had a face to face encounter with the patient, including the date of the encounter
The attestation, its accompanying signature, and the date signed, must be a separate and distinct section of, or an addendum to, the recertification form, must be clearly titled
When a nurse practitioner performs the encounter, the attestation must state that the clinical findings of that visit were provided to the certifying physician for use in determining whether the patient continues to have a life expectancy of six months or less, should the illness run its normal course

No Valid Election Statement Submitted
The services billed were not covered, as there was no valid signed notice of election (NOE) statement included with the documentation submitted for review.

How to prevent a denial:
A Medicare beneficiary must complete a NOE statement before the Hospice Medicare Benefit can begin. A beneficiary, who meets the eligibility requirement in the Code of Federal Regulations, 42 CFR - Part 418.20, may file a NOE statement with a particular hospice. The representative for this beneficiary may file the NOE if the beneficiary is physically or mentally incapacitated. The NOE statement must be signed no later than the first day for which the payment is claimed. It must also be signed if the beneficiary is re-electing the hospice Medicare benefit after a revocation or discharge from hospice.
The provider must submit a NOE statement to the intermediary for every beneficiary who elects the Hospice Medicare Benefit. A beneficiary (or his/her representative) must elect hospice care to receive it. Once the decision to receive hospice care is made, a NOE statement must be filed with a particular hospice.
All NOE statements must include the following information:
o Identification of the particular hospice which will provide care
o The beneficiary’s or representative’s acknowledgement that he or she has been given a full understanding of the palliative, rather than curative nature of hospice care, particularly the palliative rather than the curative nature of treatment
o Acknowledgement that certain Medicare services set forth in Code of Federal Regulations, 42 CFR - paragraph (d) of section 418.24 are waived by the election
o The effective date of the NOE statement, which may be the first day of hospice care or a later date, but may be no earlier than the date of the NOE statement
o The signature of the beneficiary or authorized representative
The duration of the NOE statement will be considered to continue through the initial election period and through the subsequent election periods without a break in care as long as the beneficiary remains in the care of a hospice and does not revoke the election under the provision of Code of Federal Regulations, 42 CFR - Section 418.28
When a Medicare beneficiary or authorized representative elects the hospice Medicare benefit, a NOE statement must be submitted to the Medicare Administrative Contractor (MAC) prior to the submission of the first bill

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