January 2021 Quarterly Release Temporary Hold

Each quarter, the Fiscal Intermediary Shared System (FISS) is updated to include new logic for claims processing, pricing, etc.

When the release is installed, Palmetto GBA places a temporary hold to ensure the release is installed properly. During this time, claims with dates of service of January 1, 2021, or later will be held in the status/location listed below and may be released before or on January 14, 2021, to continue processing.

Reason Code

Location Status







Home Health PPS Claims



Holds All Claims

This process does not apply to home health Requests for Accelerated Payments (RAPs) or hospice Notices of Election (NOEs).

Providers should be reminded that Medicare claims processed by the 30th day from claim receipt are considered timely. Beginning on the 31st day from receipt, interest will be applied to clean claims that have not been processed. A “clean” claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis.

January 2021 Release Dark Days for the Common Working File (CWF) Hosts

© 2020 Palmetto GBA, LLC

We frequently update our articles to reflect the latest changes and updates to Medicare, and strongly recommend you visit this article at link below to confirm you have the latest version.

Published Date:12/23/2020

Printed Date: 12/28/2020

URL: https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Home%20Health%20and%20Hospice~Articles~General~B


For the upcoming January 2021 Release, the Common Working File (CWF) will be observing Dark Days starting Thursday, December 31, 2020, through Sunday, January 3, 2021, (which includes the New Year’s Day holiday on Friday, January 1, 2021). The Dark Days are needed to ensure the completion of weekly, monthly and quarterly processing and the installation of the January 2021 Release.

The Dark Days will not affect your ability to access beneficiary eligibility, claim status, or other information through Palmetto GBA’s eServices portal (https://www.onlineproviderservices.com/ecx_improvev2/initLogin.do) .

During the Dark Days, our Interactive Voice Response (IVR) system will not have access to the CWF, so users will not be able to check beneficiary eligibility or claim status through our IVR. The IVR will be available for users to check the payment floor or the last three checks paid, and to request a duplicate remittance notice using a check number.

Smart Edits Listing and 277CA Enhancement

Palmetto GBA is excited to announce we have successfully implemented all enhancements to the 277CA report, as part of Smart Edits. Smart Edits is a process that returns pre-adjudicated claims information through claim acknowledgement transaction reports based on the Medicare 277CA. This system populates the STC*12 segment in the 2220D loop of the 277CA.

Example Smart Edit:

 Line Number  Smart Edits #  Smart Edits Message  Smart Edits Description
 24.  CPT Procedure code XXXXX is invalid. (CPT) Invalid Procedure Code
The CPT System Rule identifies claim lines that do not contain a valid procedure code. A valid procedure code is one that is present in the system and is effective.

All direct submitters will receive the Medicare 277CA report with these new Smart edits. A list of the Smart Edits appears in the link below. Claims rejecting the pre-adjudication editing process are not forwarded to the claims adjudication system. If you choose not to correct the claim, then just resubmit the claim for processing.

Other examples of how the segment will appear can be found in our current GPNet Communications Manual (see link below). If you are currently using a clearinghouse or billing service to submit your claims, please share this information with them.

TRICARE manuals now include a Patient-Driven Groupings Model (PDGM) for Home Health Agency (HHA) reimbursement

May 19, 2020

Retroactive to January 1, 2020, TRICARE manuals now include a Patient-Driven Groupings Model (PDGM) for Home Health Agency (HHA) reimbursement. Humana Military will release PDGM-reimbursed HHA claims with dates of service on or after January 1 as soon as system changes are implemented.


TRICARE’s PDGM reimbursement model closely follows Medicare’s PDGM*.

  • Reimbursement is based on 30-day periods of care vs. 60-day episodes**.
  • Therapy thresholds are no longer used to determine payments. Reimbursement is based on timing, admission source, clinical group, functional impairment level and comorbidity adjustment.
  • Health Insurance Prospective Payment System (HIPPS) codes are still reported with revenue code 0023.

*Unlike Medicare, TRICARE requires a Treatment Authorization Code (TAC).
**Authorizations for home health services, OASIS assessments and updates to patient care plans remain on a 60-day period of care.


Except for low utilization HHAs, providers must submit an initial claim, also called a Request for Anticipated Payment (RAP), and a final claim. Providers must bill in non-overlapping 30-day periods of care.

  • For 60-day episodes that began on or before December 31, 2019 and span into 2020, payment will be for the 60-day episode. For 30-day periods of care that start on our after January 1, 2020, reimbursement is based on 30-days.
  • HHAs participating in Medicare prior to January 1, 2019 will continue to receive RAP payments, now a 20/80 split. Those who began participating in Medicare on or after January 1, 2019 will receive an entire payment with the final claim.
  • HHAs with low utilization (two to six visits per 30-day period) will be paid a standardized per visit payment instead of payment for a 30-day period of care.

Medicare updates rates annually on a calendar year basis.

Note: This guidance does not apply to home health services provided to Active Duty Family Members (ADFM) under the Extended Care Health Option (ECHO).

Can I Tell If a Beneficiary Is Participating in Another Demonstration?

For a beneficiary to participate in an Innovation Model or Demonstration, the beneficiary must first choose a participating provider to be their primary care physician. When accepting a referral for home health services, make sure to ask the referring physician if the beneficiary is currently participating in a Demonstration or Innovation Model. The referring doctor (primary care physician) should have this information as they generally sign the plan of care.

For a list of CMS Innovation Models and to find out more information, visit the Innovation Models page on the CMS website.


Home Health Plans of Care: NPs, CNSs and PAs Allowed to Certify

Section 3708 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act (Pub. L. No. 116-136) amended sections 1814(a) and 1835(a) of the Social Security Act to allow Nurse Practitioners (NPs), certified Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) to certify beneficiaries for eligibility under the Medicare home health benefit and oversee their plan of care. This is a permanent change that will continue after the Public Health Emergency.

Effective for claims with dates of service on or after March 1, 2020, these non-physician practitioners may bill the following codes:

· G0179: Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care

· G0180: Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care

· G0181: Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans

The descriptors of the three codes will be revised at a later date to include the non-physician practitioner specialties.

Aetna Contracts with myNexus for Home Health Services in Texas

myNEXUS is proud to announce its partnership with Aetna to provide utilization management for home health services in Texas.

Important Announcements

  • Important COVID-19 Information:With the heightened international awareness regarding the coronavirus disease of 2019 (COVID-19), myNEXUS would like to provide important reminders for your agency. Please find the myNEXUS announcement regarding these reminders on business disruption, which includes infectious outbreaks and other occurrences that potentially impact all of us and consequently, our members/your patients located online 

Program Announcements

Effective March 1, 2020, myNEXUS will manage Aetna Medicare Advantage (MA) plans in the state of Texas. Delegated services include Claims Payment, Provider Network, and Utilization Management.

Texas Provider Notice

Home health-related requests for in-home skilled nursing, physical therapy, occupational therapy, speech therapy, home health aide, and medical social work will now require pre-authorization from myNEXUS. Claims for home health services for Aetna Medicare Advantage Members will also be paid by myNEXUS. This will occur for services administered in a home or residence for Aetna Medicare Advantage members in Texas.

Provider Materials

Please follow the links below for program materials:

In-Scope Plan List

Initial Authorization Request Form 
Re-Authorization Request Form
Out of Network Provider Request Form

Home Infusion Therapy Information
Fax Confirmation Form
Claims: EFT Form
Claims: In-Network Provider Reconsideration Form
myNEXUS Payer ID for Aetna: 34010

myNEXUS utilizes CMS National and Local Coverage Determinations (NCD and LCD’s) when applicable, or Aetna medical policies and clinical Utilization Management guidelines to facilitate appropriate evaluation of medical necessity by including assessment of the member throughout the continuum of care. A synopsis of the criteria is available to Providers and Members on request and free of charge by calling myNEXUS at 844-411-9622 or by emailing provider_network@myNEXUScare.com.

Provider Authorization Portal

myNEXUS Portal
For information on how to register for the portal, please click this link.

Contact Us

Phone: 1-833-585-6262

CARES Act Provider Relief Fund

President Trump is providing support to healthcare providers fighting the COVID-19 pandemic. On March 27, 2020, the President signed the bipartisan CARES Act that provides $100 billion in relief funds to hospitals and other healthcare providers on the front lines of the coronavirus response. This funding will be used to support healthcare-related expenses or lost revenue attributable to COVID-19 and to ensure uninsured Americans can get testing and treatment for COVID-19.

Immediate infusion of $30 billion into healthcare system

Recognizing the importance of delivering funds in a fast and transparent manner, $30 billion is being distributed immediately – with payments arriving via direct deposit beginning April 10, 2020 – to eligible providers throughout the American healthcare system. These are payments, not loans, to healthcare providers, and will not need to be repaid.

Who is eligible for initial $30 billion

  • All facilities and providers that received Medicare fee-for-service (FFS) reimbursements in 2019 are eligible for this initial rapid distribution.
  • Payments to practices that are part of larger medical groups will be sent to the group’s central billing office.
    • All relief payments are made to the billing organization according to its Taxpayer Identification Number (TIN).
  • As a condition to receiving these funds, providers must agree not to seek collection of out-of-pocket payments from a COVID-19 patient that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.
  • This quick dispersal of funds will provide relief to both providers in areas heavily impacted by the COVID-19 pandemic and those providers who are struggling to keep their doors open due to healthy patients delaying care and cancelled elective services.

How are payment distributions determined

  • Providers will be distributed a portion of the initial $30 billion based on their share of total Medicare FFS reimbursements in 2019. Total FFS payments were approximately $484 billion in 2019.
  • A provider can estimate their payment by dividing their 2019 Medicare FFS (not including Medicare Advantage) payments they received by $484,000,000,000, and multiply that ratio by $30,000,000,000. Providers can obtain their 2019 Medicare FFS billings from their organization’s revenue management system.
  • As an example: A community hospital billed Medicare FFS $121 million in 2019. To determine how much they would receive, use this equation:
    • $121,000,000/$484,000,000,000 x $30,000,000,000 = $7,500,000

What to do if you are an eligible provider

  • HHS has partnered with UnitedHealth Group (UHG) to provide rapid payment to providers eligible for the distribution of the initial $30 billion in funds.
  • Providers will be paid via Automated Clearing House account information on file with UHG or the Centers for Medicare & Medicaid Services (CMS).
    • The automatic payments will come to providers via Optum Bank with “HHSPAYMENT” as the payment description.
    • Providers who normally receive a paper check for reimbursement from CMS, will receive a paper check in the mail for this payment as well, within the next few weeks.
  • Within 30 days of receiving the payment, providers must sign an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment. The portal for signing the attestation will be open the week of April 13, 2020, and will be linked on this page.
  • HHS’ payment of this initial tranche of funds is conditioned on the healthcare provider’s acceptance of the Terms and Conditions – PDF, which acceptance must occur within 30 days of receipt of payment.  If a provider receives payment and does not wish to comply with these Terms and Conditions, the provider must do the following: contact HHS within 30 days of receipt of payment and then remit the full payment to HHS as instructed.  Appropriate contact information will be provided soon.

Is this different than the CMS Accelerated and Advance Payment Program?

Yes. The CMS Accelerated and Advance Payment Program has delivered billions of dollars to healthcare providers to help ensure providers and suppliers have the resources needed to combat the pandemic. The CMS accelerated and advance payments are a loan that providers must pay back. Read more information from CMS.

How this applies to different types of providers

All relief payments are being made to providers and according to their tax identification number (TIN). For example:

  • Large Organizations and Health Systems: Large Organizations will receive relief payments for each of their billing TINs that bill Medicare. Each organization should look to the part of their organization that bills Medicare to identify details on Medicare payments for 2019 or to identify the accounts where they should expect relief payments.
  • Employed Physicians: Employed physicians should not expect to receive an individual payment directly. The employer organization will receive the relief payment as the billing organization.
  • Physicians in a Group Practice: Individual physicians and providers in a group practice are unlikely to receive individual payments directly, as the group practice will receive the relief fund payment as the billing organization. Providers should look to the part of their organization that bills Medicare to identify details on Medicare payments for 2019 or to identify the accounts where they should expect relief payments.
  • Solo Practitioners: Solo practitioners who bill Medicare will receive a payment under the TIN used to bill Medicare.

Priorities for the remaining $70 billion

The Administration is working rapidly on targeted distributions that will focus on providers in areas particularly impacted by the COVID-19 outbreak, rural providers, providers of services with lower shares of Medicare reimbursement or who predominantly serve the Medicaid population, and providers requesting reimbursement for the treatment of uninsured Americans.

Ensuring Americans are not surprised by bills for COVID-19 medical expenses

The Trump Administration is committed to ensuring that Americans are protected against financial obstacles that might prevent them from getting the testing and treatment they need from COVID-19.

  • As announced in early April, a portion of the $100 billion Provider Relief Fund will be used to reimburse healthcare providers, at Medicare rates, for COVID-related treatment of the uninsured.
    • As a condition, providers are obligated to abstain from “balance billing” any patient for COVID-related treatment.
  • The Families First Coronavirus Response Act requires private insurers to cover an insurance plan member’s cost-sharing payments for COVID-19 testing.
  • President Trump has also secured commitments from private insurers, including Humana, Cigna, UnitedHealth Group, and the Blue Cross Blue Shield system to waive cost-sharing payments for treatment related to COVID-19 for plan members.

Home Health Agencies: CMS Flexibilities to Fight COVID-19

The Trump Administration is issuing an unprecedented array of temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic. Made possible by President Trump’s recent emergency declaration and emergency rule making, these temporary changes will apply immediately across the entire U.S. healthcare system for the duration of the emergency declaration. The goals of these actions are to 1) to ensure that local hospitals and health systems have the capacity to handle a potential surge of COVID-19 patients through temporary expansion sites (also known as CMS Hospital Without Walls); 2) remove barriers for physicians, nurses, and other clinicians to be readily hired from the community or from other states so the healthcare system can rapidly expands its workforce; 3) increase access to telehealth in Medicare to ensure patients have access to physicians and other clinicians while keeping patients safe at home; 4) expand in-place testing to allow for more testing at home or in community based settings; and 5) put Patients Over Paperwork to give temporary relief from many paperwork, reporting and audit requirements so providers, health care facilities, Medicare Advantage and Part D plans, and States can focus on providing needed care to Medicare and Medicaid beneficiaries affected by COVID-19.

Medicare Telehealth

• Home Health Agencies (HHAs) can provide more services to beneficiaries using telehealth within the 30 day episode of care, so long as it’s part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care. We acknowledge that the use of such technology may result in changes to the frequency or types of in-persons visits outlined on existing or new plans of care.

Patients Over Paperwork

Homebound Definition: A beneficiary is considered homebound when their physician advises them not to leave the home because of a confirmed or suspected COVID-19 diagnosis or if the patient has a condition that makes them more susceptible to contract COVID-19. As a result, if a beneficiary is homebound due to COVID-19 and needs skilled services, an HHA can provide those services under the Medicare Home Health benefit.

• Plans of Care and Certifying/Recertifying Patient Eligibility: HHS is utilizing enforcement discretion with regards to the requirements at §§ 409.43 and 424.22 in order to allow a patient to be under the care of a nurse practitioner or clinical nurse specialist (as such terms are defined in section 1861(aa) (5)) who is working in accordance with State law, or a physician assistant (as defined in section 1861(aa)(5)) who is working in accordance with State law, and for such physician/practitioner: (1) order home health services; (2) establish and periodically review a plan of care for home health services (e.g., sign the plan of care), (3) certify and re-certify that the patient is eligible for Medicare home health services. This will provide the flexibility needed for more timely initiation of services for home health patients, while allowing providers and patients to practice social distancing. HHS will not conduct audits to ensure that only physicians provided orders, signed and dated the plans of care, and certified/recertified patient eligibility for claims submitted during this public health emergency.

Reporting: CMS is providing relief to HHAs on the timeframes related to OASIS Transmission. This waiver includes extending of the 5-day completion requirement for the comprehensive assessment and waiving the 30-day OASIS submission requirement. HHAs are expected to complete the comprehensive assessment within 30 days and delayed submission is permitted. We continue to require that patients still have an assessment to determine and be able to appropriate meet their care needs.

Initial Assessments: By waiving 42 CFR § 484.55(a), home health agencies can perform initial assessments and determine patients’ homebound status remotely or by record review. This will allow patients to be cared for in the best environment for them while supporting infection control and reducing impact on acute care and long-term care facilities. This will allow for maximizing coverage if there are limited physician and advanced practice clinicians, and will allow those
clinicians to focus on caring for patients with the greatest acuity.

Requests for Anticipated Payments (RAPs): MACs can extend the auto-cancellation date of RAPs during emergencies. RAPs are a pre-payment for home health services.

Review Choice Demonstration for Home Health Services: CMS is offering home health agencies in the Review Choice Demonstration for Home Health Services the option of pausing their participation for the duration of the Public Health Emergency. Home Health agencies do not have to do anything for the pause to go into effect.

Medicare appeals in Fee for Service, Medicare Advantage (MA) and Part D

• CMS is allowing Medicare Administrative Contractors (MACs) and Qualified Independent Contractor (QICs) in the FFS program 42 CFR 405.942 and 42 CFR 405.962 and MA and Part D plans, as well as the Part C and Part D Independent Review Entity (IREs), 42 CFR 562, 42 CFR 423.562, 42 CFR 422.582 and 42 CFR 423.582 to allow extensions to file an appeal;

• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966 and the Part C and Part D IREs to waive requirements for timeliness for requests for additional information to adjudicate appeals; MA plans may extend the timeframe to adjudicate organization determinations and reconsiderations for medical items and services (but not Part B drugs) by up to 14 calendar days if: the enrollee requests the extension; the extension is justified and in the enrollee’s interest due to the need for additional medical evidence from a noncontract provider that may change an MA organization’s decision to deny an item or service; or, the extension is justified due to extraordinary, exigent, or other non-routine circumstances and is in the enrollee’s interest 42 CFR § 422.568(b)(1) (i), § 422.572(b)(1) and § 422.590(f)(1);

• CMS is allowing MACs and QICs in the FFS program 42 C.F.R 405.910 and MA and Part D plans, as well as the Part C and Part D IREs to process an appeal even with incomplete Appointment of Representation forms 42 CFR § 422.561, 42 CFR § 423.560. However, any communications will only be sent to the beneficiary;

• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966 and MA and Part D plans, as well as the Part C and Part D IREs to process requests for appeal that don’t meet the required elements using information that is available 42 CFR § 422.562, 42 CFR § 423.562.

• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966 and MA and Part D plans, as well as the Part C and Part D IREs, 42 CFR 422.562, 42 CFR 423.562 to utilize all flexibilities available in the appeal process as if good cause requirements are satisfied.

Accelerated/Advance Payments: In order to increase cash flow to providers impacted by COVID-19, CMS has expanded our current Accelerated and Advance Payment Program. An accelerated/advance payment is a payment intended to provide necessary funds when there is a disruption in claims submission and/or claims processing. CMS is authorized to provide accelerated or advance payments during the period of the public health emergency to any Medicare provider/supplier who submits a request to the appropriate Medicare Administrative Contractor (MAC) and meets the required qualifications. Each MAC will work to review requests and issue payments within seven calendar days of receiving the request. Traditionally repayment of these advance/accelerated payments begins at 90 days, however for the purposes of the COVID-19 pandemic, CMS has extended the repayment of these accelerated/advance payments to begin 120 days after the date of issuance of the payment.

Providers can get more information on this process here: www.cms.gov/files/document/Acceleratedand-Advanced-Payments-Fact-Sheet.pdf

Provider Enrollment: CMS has established toll-free hotlines for all providers as well as the following
flexibilities for provider enrollment:
o   Waive certain screening requirements.
o   Postpone all revalidation actions.
o   Expedite any pending or new applications from providers.

Cost Reporting

• CMS is delaying the filing deadline of certain cost report due dates due to the COVID-19 outbreak. We are currently authorizing delay for the following fiscal year end (FYE) dates. CMS will delay the filing deadline of FYE 10/31/2019 cost reports due by March 31, 2020 and FYE 11/30/2019 cost reports due by April 30, 2020. The extended cost report due dates for these October and November FYEs will be June 30, 2020. CMS will also delay the filing deadline of the FYE 12/31/2019 cost reports due by May 31, 2020. The extended cost report due date for FYE 12/31/2019 will be July 31, 2020.

COVID-19 Diagnostic Testing

• If a patient is already receiving Medicare home health services, the home health nurse, during an otherwise covered visit, could obtain the sample to send to the laboratory for COVID-19 diagnostic testing.


Ordering Medicaid Home Health Services and Equipment: Medicaid home health regulations now allow non-physician practitioners to order medical equipment, supplies and appliances, home health nursing and aide services, and physical therapy, occupational therapy or speech pathology and audiology services, in accordance with state scope of practice laws.

Waived onsite visits for both HHA Aide Supervision: CMS is waiving the requirements at 484.80(h), which require a nurse to conduct an onsite visit every two weeks. This would include waiving the requirements for a nurse or other professional to conduct an onsite visit every two weeks to evaluate if aides are providing care consistent with the care plan, as this may not be physically possible for a period of time. This waiver is also temporarily suspending 2-week aide supervision requirement at 42 CFR §484.80(h)(1) by a registered nurse for home health agencies, but virtual supervision is encouraged during the period of the waiver.

Additional Guidance

• The Interim Final Rule and waivers can be found at: https://www.cms.gov/about-cms/emergencypreparedness-response-operations/current-emergencies/coronavirus-waivers.

• CMS has released guidance to describe standards of practice for infection control and prevention of COVID-19 in home health agencies at https://www.cms.gov/files/document/qso-20-18-hha.pdf.

• CMS has released guidance to providers related to relaxed reporting requirements for quality reporting programs at https://www.cms.gov/newsroom/press-releases/cms-announces-reliefclinicians-providers-hospitals-and-facilities-participating-quality-reporting.

2019-Novel Coronavirus (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs)

Q. Is CMS suspending most Medicare Fee-For-Service (FFS) medical review during the Public Health Emergency (PHE) period for the COVID-19 pandemic?

A. Yes, CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.

Q. Is CMS waiving signature requirements on proof of delivery slips in response to the COVID-19 pandemic, for Dates of Service (DOS) within the PHE for the COVID-19 pandemic?

A. Yes, given the nature of the pandemic and the inability to collect signatures during this time, CMS will not be enforcing the signature requirement. Typically, Part B drugs and certain Durable Medical Equipment (DME) covered by Medicare require proof of delivery and/or a beneficiary’s signature. Suppliers should document in the medical record the appropriate date of delivery and that a signature was not able to be obtained because of COVID-19.

Q. Is CMS pausing the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model?

A. Yes. Effective March 29, 2020, certain claims processing requirements for the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model will be paused in the model states of Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia until the PHE for the COVID-19 pandemic has ended. During the pause, claims for repetitive, scheduled non-emergent ambulance transports submitted on or after March 29, 2020 and before the end of the PHE for the COVID-19 pandemic in these states will not be stopped for pre-payment review if prior authorization has not been requested by the fourth round trip in a 30-day period. During the pause, the MAC will continue to review any prior authorization requests that have already been submitted, and ambulance suppliers may continue to submit new prior authorization requests for review during the pause. Claims that have received a provisional affirmative prior authorization decision and are submitted with an affirmed unique tracking number (UTN) will continue to be excluded from future medical review. Following the end of the PHE for the COVID-19 pandemic, the MACs will conduct postpayment review on claims otherwise subject to the model that were submitted and paid during the pause.

Q. The model is currently scheduled to end on December 1, 2020. Given this pause, will CMS extend the model beyond that date?

A. At this time, CMS is not planning an extension beyond December 1, 2020. If this did occur, CMS would provide proper public notice. Further, the model will not be expanded in any other state during the PHE.

Q. How does this pause in the model affect a determination as to whether the model meets the criteria to be expanded nationwide, as provided under section 1834(l)(16) of the Social Security Act, and any next steps for expansion?

A. The pause in the model does not affect the efforts to expand the model nationwide as provided under section 1843(l)(16). CMS will continue its efforts to prepare for expansion after the PHE for the COVID-19 pandemic has ended.

Q. How does this pause in the model affect evaluation of the model?

A. The evaluation of the model will take into consideration the pause for the PHE for the COVID-19 pandemic. Those claims will be reviewed through postpayment review and will still be factored into the evaluation.

Q. Is CMS pausing the Review Choice Demonstration for Home Health Services?

A. Yes. Effective March 29, 2020, certain claims processing for the Review Choice Demonstration (RCD) for Home Health Services will be paused in Illinois, Ohio, and Texas, until the PHE for the COVID-19 pandemic has ended. During the pause, the MACs will process claims submitted prior to the emergency period under normal claims processing requirements. Claims for home health services furnished on or after March 29, 2020 and before the end of the PHE for the COVID-19 pandemic in these states will not be subject to the review choices made by the home health agency under the demonstration. However, the MAC will continue to review any pre-claim review requests that have already been submitted, and providers may continue to submit new pre-claim review requests for review during the pause. Claims that have received a provisional affirmative pre-claim review decision and are submitted with an affirmed Unique Tracking Number (UTN) will continue to be excluded from future medical review. Home health agencies participating in pre-claim review may submit their claims without requesting such approval from the MAC and claims submitted without a UTN will not be stopped for prepayment review and will not receive a 25% payment reduction. HHAs participating in the other review choices (prepayment or postpayment review) will not receive Additional Documentation Requests (ADRs) during the pause, and ADRs that were issued prior to the PHE will be released and processed as normal. Following the end of the PHE for the COVID-19 pandemic, the MAC will conduct postpayment review on claims subject to the demonstration that were submitted and paid during the pause.

The demonstration will not begin in North Carolina and Florida on May 4, 2020, as previously scheduled. CMS will provide notice on its demonstration website rescheduling the start of the demonstration, once the PHE has ended.

Q. The demonstration is currently scheduled to end on May 31, 2024. Given this pause, will CMS extend the demonstration beyond that date?

A. At this time, CMS is not planning an extension beyond May 31, 2024. If this did occur, CMS would provide proper public notice