Many agencies have been faced with the dilemma of how to obtain a Medicare denial in order to bill Medicaid for a patient who is dual eligible and is not homebound, or does not have a Medicare skilled need. Agencies have in the past received conflicting and confusing information from many sources. Therefore the Home Care Association of Colorado (HCAC) Regulatory and Reimbursement Council arranged to meet via teleconference with representatives from Cahaba (Medicare Intermediary), ACS (Medicaid Intermediary), CMS Region VIII, Health Care Policy and Financing (HCPF – Medicaid), The National Association of Home Care (NAHC) and the Massachusetts Home Care Association. The teleconference was conducted in order to establish a clear process for dealing with the dual eligible patient who is not eligible for Medicare home health coverage for the episode of care and how to indicate that to Medicaid so services can be billed and reimbursed in a timely manner. The following process was agreeable to all participants at the close of the teleconference.

SCENARIO:

• If patient chooses to select the B.1 box, signs and dates the ABN, the date should be the same as the Start of Care on the 485.
• When billing for the services on the UB 92, the agency would use occurrence code 51 (which means Medicare has not been billed). Answer yes to the question – Does the Patient have Medicare? and in the following "Date Denied" box put the date the ABN was signed (same as the SOC (start of care). The agency is indicating to ACS (Medicaid Intermediary) that the patient has chosen to not use their Medicare home care benefit because they don’t qualify for Medicare coverage due to homebound status. It is understood that the patient has signed the HHABN. The agency does not need to send anything to Medicare and can bill Medicaid.
• The signed HHABN is retained in the patient’s record and may be requested by Medicaid during an audit, or a surveyor during a survey of the agency.
• If the patient chooses to mark Option A on the HHABN form, the agency would use condition code 20 (CC20) on the UB 92. This triggers an ADR (Additional Developmental Request). When the ADR is received and you send your documentation to the Medicare Intermediary you MUST send the HHABN. The absence of an HHABN may result in the provider being held liable under the limitations of liability provisions, if all or part of the claim is denied. See the Medicare A Newsline of September 1, 2003 Vol. 10, No. 12, p.48. There is an article "Changes in Requesting HHABNs for Demand Bills." This is the process only if the patient chooses Option A on the HHABN.

Additional information:

There have been some questions concerning time limits and the HHABN. A response to the question was received from the National Association for Home Care Dept. of Regulatory Affairs: "The statement made during the Open Door Forum that ‘all ABNs must be reissued annually’ is contrary to a Q&A response that CMS provided to Home Health agencies in the past. According to the CMS staff person, the statement that all ABNs must be renewed annually is true only for providers using ABN form R-131. Home health agencies use form R-296."

Therefore, home health agencies are not required to reissue ABN forms R-296 annually. The only time a new HHABN is required is if there is a change in the facts of a prior ABN (or in those very limited situations where a home health provider issues an ABN form R –131 for non-home health services.)

The above statement refers to Medicare and Medicaid patients alike.

 

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