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HH01: History of Home Health - 3.0 Lecture Hours

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HH09: Follow-Up & Post Claims Submission – Five Levels of Appeal Part 2 Copy

Ian V. Chestnut July 26, 2021

The Five Levels of Appeal – Part 2


Medical Review of Claims and Documentation

The Centers for Medicare & Medicaid Services (CMS) utilizes a number of contractors to conduct medical review of claims and documentation, including:

Medicare Administrative Contractors (MACs)

Comprehensive Error Rate Testing (CERT) contractors

  • The Comprehensive Error Rate Testing (CERT) program was established by the Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of claim payment in the Medicare Fee-For-Service (FFS) Program.
  • The intent of the CERT program is to protect the Medicare Trust Fund by identifying errors and assessing error rates, at both the national and regional levels. Findings from the CERT program are used to identify trends that are driving the errors, such as errors by a specific provider type or service, and assist with allocation of future program integrity resources. The CERT error rate is also used by CMS to evaluate the performance of Medicare contractors

Recovery Auditors (RAs)

  • The goal of the Recovery Audit program is to identify and reduce improper payments made on claims for services  provided to Medicare beneficiaries. All providers, including home health and hospice providers, may be subject to claims review by a RAC

Zone Program Integrity Contractors (ZPICs)/UPIC

  • The goal of the UPIC is to identify cases of suspected fraud, investigate them, and take action to ensure any inappropriate Medicare payments are recouped

Supplemental Medical Review Contractor (SMRC)

  • The SMRC conducts medical review of Medicare Part A and B claims nationwide. The SMRC evaluates medical records to determine whether Medicare claims were billed in compliance with coverage, coding, payment, and billing practices.

Medicare Program Integrity Manual



UPIC Issues

  • Billing for services not furnished
  • Pattern of overutilization
  • Vacant supplier/provider location
  • Medically unnecessary services
  • Stolen provider/beneficiary info
  • Schemes of collusion (e.g. kickbacks)



  • States/RAC’s Must:
  • Coordinate audits with other auditing entities
  • Set limits on number and frequency of medical records for revies
  • Maintain 1 FTE Medical Director who is a M.D or D.O.
  • Develop education and outreach programs
  • Report fraud to Medicaid Fraud Control Units
  • Adhere to 3 year look-back period
  • Hire certified coders unless state determines not needed
  • Incentivize RAC’s to detect underpayments



CMS Red Flags

Claims data:

  • Episode Timing
  • Inpatient Stays Overlap
  • Irregular billing patterns
  • Physician
  • High therapy utilization
  • Over utilization of therapy
  • Peer Analysis
  • Same diagnosis
  • Same HIPPS



Auto Cancel Red Flags

  • Providers that are identified to have RAPs auto-canceled versus the total number of final claims processed that are high will be notified that their current billing practices are unacceptable and their RAPs are being monitored. If improvement is not noted within a reasonable amount of time, future RAPs may be set to pay at zero percent.
  • Providers identified with more than 76 percent of RAP auto-cancels versus the total number of their final claims processed during a specified period of time, will be notified that their RAPs will be set to pay at zero percent. The payment suppression does not impact the provider’s ability to submit final claims.
  • When a provider is placed on RAP payment suppression, they are asked to submit a Corrective Action Plan (CAP). The CAP should contain the following:
  • A statement of the problem or weakness that caused the delay in filing final claims
  • Proposed solutions to the problem
  • State who is responsible for the monitoring the CAP
  • Any salient information is useful



New Condition Code 54 for Reporting Home Health Episodes with No Skilled Visits

MLN Matters® Number: MM9474 Revised Related Change Request (CR) #: CR 9474
Related CR Release Date: June 28, 2016 Effective Date: Claims received on or after July 1, 2016
Related CR Transmittal #: R3553CP Implementation Date: July 5, 2016

Provider Action Needed

CR 9474 informs you of revisions of the Medicare billing instructions for home health claims to allow the use of a new condition code – 54. The code indicates that the HHA provided no skilled services during the billing period, but the HHA has documentation on file of an allowable circumstance. Make sure that your billing staffs are aware of these changes.


Enforcing this requirement on claims for subsequent episodes of HH care could not be automated using previously existing codes. There may be circumstances which prevent the HHA from delivering the skilled services planned for an episode, such as an unexpected inpatient admission. Determining whether payment is allowable requires development of the claim. Chapter 7, Section 40.1.3, of the “Medicare Benefits Policy Manual” states: “Since the need for ‘intermittent’ skilled nursing care makes the patient eligible for other covered home health services, the intermediary should evaluate each claim involving skilled nursing services furnished less frequently than once every 60 days. In such cases, payment should be made only if documentation justifies a recurring need for reasonable, necessary, and medically predictable skilled nursing services.” Medicare requested the National Uniform Billing Committee to create a new code that would allow the HHA to indicate upon submission that such documentation exists. A new condition code 54 is effective on July 1, 2016 and is defined as “No skilled HH visits in billing period. Policy exception documented at the HHA.” Submission of this code will streamline claims processing for both the payer and provider. Claims without skilled visits that are submitted without the new condition code will be returned to the provider. This will allow the HHA to:  Add any accidentally omitted skilled services to the claim;

Submit the claim as noncovered, if appropriate; or

Append the new condition code. These actions will prevent unnecessary reviews and denials for the HHA and allow Medicare to better target medical review resources.



Why is this happening?

  • Documentation
  • Requirements of face to face not met
  • Requested medical records not submitted in timely manner
  • Information provided doesn’t support medical necessity
  • Appropriate OASIS not submitted
  • POC/certification signed but not dated



Requested medical records not submitted in timely manner

  • Provider has 30 days from the time Additional Development Request was generated to respond
  • Clerical assignment to log in and track
  • Set deadline 72 hours before true deadline and live by it!
  • Establish a uniform process that ensures you have time to review the documents before sending them.
  • Monitor your direct data entry (DDE)
  • Always attach copy of ADR request to top of what is sent.