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HH01: History of Home Health - 3.0 Lecture Hours

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Module 3, Topic 1
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HH05: Home Health Claims – Eligibility Requirements Copy

Ian V. Chestnut July 26, 2021

Eligibility Requirements (HETS)



!!!!!!!!ENDED 12/31/2019!!!!!!!!



  • HIPAA Eligibility Transaction System (HETS)
  • Designed after 5010 went into effect
  • Replaced the Common Working File (CWF)  with more detailed information
  • The allowable date span is up to 27 months in the past and up to 4 months in the future, based on the date the transaction was received
  • Information will be seen by both Part A and Part B providers
  • Batches are not allowed yet
  • Available 24/7; unlike DDE



Illustrates the allowable request date ranges

Table 10 – Request Date Calendar



DDE is going away




Why Check Home Health Beneficiary Eligibility Information?

  • Entitled to Medicare Part A, Part B, or both Part A and Part B
  • Ensure you have correct information
  • Enrolled in a Medicare Advantage (MA) plan
  • Enrolled with another insurance that is primary over Medicare
  • In an open 60-day HH episode with another agency
  • A prior/current hospice election period
  • Any inpatient stays
  • Met the therapy cap for the calendar year Eligibility records



Information Necessary to Check Eligibility ​

You must have the following 4 pieces of information about the beneficiary to check eligibility: ​

  1. HIC (Health Insurance Claim)/MBI (Medicare Beneficiary Identifier) Number (also called their Medicare number) ​
  2. First initial of first name ​
  3. Last name – If the beneficiary’s name is John Smith Jr., enter “SMITHJR” ​
  4. Date of birth (MMDDCCYY format) ​

You should verify the information listed above matches the information on the beneficiary’s red, white and blue Medicare card.


Specific Information to Check for:

  • Name Spelling
  • Date of Birth
  • HIC #
  • Sex
  • Date of Death


The name, address, website & telephone # of the MA will be provided

New Insurance type codes

  • HM= HMO Medicare Non-Risk
  • HN= HMO Medicare Risk
  • IN= Indemnity
  • PR= Preferred Provider Organization
  • PS= Point of Service



MA Plan & Part C Enrollment

Additional Bill Codes
Medicare Beneficiary “locked in” to MCO

  • A – FI should process all claims
  • B – MCO should process only in-plan Part A claims and in- area Part B claims
  • C – MCO should process all claims

Medicare Beneficiary NOT “locked in” to MCO

  • 1 – FI should process all claims
  • 2 – MCO should process only in-plan Part A claims and in-area Part B claims



Determines Medicare Secondary Payer Information:

Classifies the type of MSP

  • 12 = Working Elderly
  • 13 = End Stage Renal Disease
  • 14= Auto/No Fault
  • 15 = Workers’ Compensation
  • 16 = Public Health
  • 41 = Black Lung
  • 42 = Veteran’s Administration
  • 43 = Disabled
  • 47 = Other Liability Insurance is Primary

Gives the MSP effective & termination date
Policy Number
Insurance Company Name


Determines Previous Home Health Episode Information:

  • NPI # of the previous agency
  • Provider number of the agency
  • MAC for the agency
  • Date of earliest & latest billing
  • Patient status with the agency
  • Determines late or early episode status


Determining Adjacent Episodes/Periods

Adjacent episodes/periods are best described as a series of episodes/periods, with one or more agencies that have less than a 60 day gap between the NATURAL END of one episode/period to the start of the next episode/period.

(M0110) Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an “early” episode or a “later” episode in the patient’s current sequence of adjacent Medicare home health payment episodes?

  • 1 – Early
  • 2 – Later
  • UK – Unknown
  • NA – Not Applicable: No Medicare case mix group to be defined by this assessment.


M0110 Episode Timing

  • Adjacent episodes/period are calculated from the end of payment episode/period
  • PPAs (formerly PEPs) do count toward episode/period timing
  • Only tradition Medicare episodes/periods are counted
  • The 60 day gap rule remains the same under PDGM in order for episode/period timing to be considered “early” again.
  • Under PDGM, early is now only a 30 day span compared to a 120 day span previously under PPS


New to Hospice Care Periods Business Rules

  • NPI #s will be seen now
  • Beneficiary in Hospice Care
    • 0 – Not revoked, open spell
  • Beneficiary with Hospice Care Revoked
    • 1 – Revoked by notice of revocation
    • 2 – Revoked by notice of revocation with a non-payment code of “N” and an occurrence code of “42”
    • 3 – Revoked by a Hospice claim with an occurrence code of “23”



Medicare Customer Assistance
Regarding Eligibility
[email protected]
Monday-Friday 7a – 7p ET