- Medicare Hospice Quick Reference Sheet
- Hospice Certifying Physician Medicare Enrollment Information
- Hospice Claim Reporting Requirements for Attending and Certifying Physicians
- 17729 Hospice Claim Edit for Certifying Physicians
- Hospice Notice of Election Termination/Revocation (Type of Bill 8xB)
- Hospice Room and Board Denials
- Professional Services During a Patient Hospice Election
- Counting 60-Day Election Periods
- Untimely Filed Notice of Election Circumstance Exception: Medicare Beneficiary Is Granted Retroactive Medicare Entitlement
- Hospice Billing Codes Chart
- Appropriate Use of Occurrence Code 27 and Occurrence Span Code 77
- Hospice Notice of Change of Ownership
- Filing an Electronic Notice of Change of Ownership (TOB 8XE)
- Hospice Change of Ownership
- Filing an Electronic Notice of Cancelation (Type of Bill 8XD)
- Filing an Electronic Notice of Transfer (Type of Bill 8XC)
- Counting 60-Day Election Periods - Leap Year
- Hospice Site of Service Codes
- Billing Hospice Physician, Nurse Practitioner and Physician Assistant Services (Related To Terminal Diagnosis)
- Hospice Visit Reporting
- The Medicare Hospice Benefit: Effects on Other Provider Types
- Counting 90-Day Election Periods - Leap Year
- Reporting Hospice Discharges, Revocations and Transfers
- Avoiding Reason Code 7C625: Appropriate Use of Remarks on Final Hospice Claims
- Hospice Claim Submission Job Aid
- Counting 90-Day Election Periods
- Hospice Quality Reporting Program
- Filing an Electronic Notice of Election (Type of Bill 8XA)
- Value-Based Insurance Design Model Hospice Benefit Component Overview
- Documentation for Hospice Transfers
- Hospice Billing Instructions for Influenza, Pneumococcal and Hepatitis B Vaccines
- Canceling a Hospice Notice of Election
- How to Bill When the Hospice Face-to-Face is Late from a Previous Benefit Period
- Hospice Payment Rates
- Billing Medicare for a Denial - Condition Code 21
- Reminder on Deleting Revenue Code Line(s) in the Fiscal Intermediary Standard System Direct Data Entry System
Untimely Filed Notice of Election Circumstance Exception: Medicare Beneficiary Is Granted Retroactive Medicare Entitlement
Table of Contents
- Untimely Filed Notice of Election Circumstance Exception: Medicare Beneficiary Is Granted Retroactive Medicare Entitlement
- Exceptional Circumstance for Untimely-Filed NOE
- Medicare Hospice Coverage Requirements
- Documentation Requirements
Untimely Filed Notice of Election Circumstance Exception: Medicare Beneficiary Is Granted Retroactive Medicare Entitlement
As part of the hospice election process under the Medicare hospice benefit, the hospice must file an NOE to inform the Medicare claims processing systems that a beneficiary is under a hospice election. Prompt filing of the hospice NOE with the Medicare contractor is required to properly enforce this waiver and prevent inappropriate payments to nonhospice providers.
As stated in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance, Section 20.2.1.1, timely-filed hospice NOEs shall be filed within five calendar days after the hospice admission date. In instances where an NOE is not timely-filed, Medicare shall not cover and pay for the days of hospice care from the hospice admission date to the date the NOE is submitted to, and accepted by, the Medicare contractor. These days shall be provider liable and the provider shall not bill the beneficiary.
Exceptional Circumstance for Untimely-Filed NOE
There may be some circumstances that may be beyond the control of the hospice where it may not be possible to timely-file the NOE within five calendar days after the effective date of election. Therefore, CMS regulations allow for exceptions. Please refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11 Processing Hospice Claims, Section 20.1.1 for a complete list of exceptional circumstances.
When a Medicare beneficiary is entitled to Medicare they may not be notified of the Medicare entitlement for several months after the effective election date. Therefore, it would be beyond the control of a hospice provider to enter an NOE timely, when the beneficiary is granted retroactive entitlement. NGS will grant an exceptional circumstance for an untimely filing of an NOE when coverage criteria has been met and verified. Claims received with an occurrence code 77 and a KX modifier will be suspended and generate a non-medical ADR. NGS will review the requested information to validate that all coverage requirements and retroactive entitlement have been met.
Medicare Hospice Coverage Requirements
Requirements for coverage under the Medicare hospice benefit are that the individual must be entitled to Medicare Part A and the individual must be certified as being terminally ill, with a life expectancy of six months or less if the illness runs its normal course. An individual who receives retroactive Medicare entitlement is entitled to Medicare hospice services effective on the first day of that entitlement.
A valid election statement must meet the criteria listed in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance, Section 20.2.1 which provides the content of the election statement and a valid certification of terminal illness.
Note: CMS has determined it would be acceptable for the election statement to contain language that states, “in the event I become eligible for Medicare, I or a representative (as applicable) acknowledge and understands that certain Medicare services are waived by the election.” Upon notification of the beneficiary's retroactive entitlement the provider should obtain a new election form that satisfies all the requirements set forth by CMS for a valid election.
Documentation Requirements
Upon receiving a request for an exception to the timely-filed NOE policy for retroactive Medicare entitlement, the MAC must also request and receive supporting documentation that the individual meets eligibility requirements under the Medicare hospice benefit. Specifically, the MAC must request and receive:
- Proof of retroactive Medicare entitlement;
- The certification of terminal illness that meets the criteria set forth in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance Section 20.1; and
- The hospice election statement that meets the criteria set forth in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance Section 20.2.1.
A retroactive Medicare entitlement qualifies as one of the exceptions to a timely-filed NOE as this would be a circumstance that is beyond the hospice’s control. Therefore, if the requesting hospice’s supporting documentation meets the three criteria listed above, NGS will not hold providers liable for those days from the effective date of the retroactive Medicare entitlement to the date of the filing of the NOE, and to pay claims from the effective date of the hospice election for which there is entitlement under Medicare.
Tip: When submitting a claim for an untimely NOE that meets the exceptional circumstance be sure to include in Remarks, “Late NOE due to retroactive Medicare entitlement.” Once the exact nature of why an exceptional circumstance is requested has been stated, the hospice may add any additional comments to assist in further clarifying the circumstance.
Revised 5/23/2024