Eligibility Query to Determine Status

30.1 - Eligibility Query to Determine Status (Rev. 10758; Issued: 05-11-21; Effective: 01-01-22; Implementation: 08-11-21) Under the HH PPS and home health consolidated billing one HHA is considered the “primary” home health agency in billing situations. This primary agency is the only agency that may bill Medicare for home care for a given homebound beneficiary at a specific time. When a homebound beneficiary seeks care from an HHA or from an institutional therapy provider subject to home health consolidated billing, the provider needs to determine if the beneficiary is already being served by an HHA - an agency that then would be considered primary. Providers may send an inquiry to determine the beneficiary’s entitlement and eligibility status into the Common Working File or CWF, through their A/B MAC (A) or (HHH). They must send the ASC X12 270 Health Care Eligibility Inquiry transaction set and will receive the ASC X12 271 Health Care Eligibility Response transaction set in response, in order to comply with the requirements of the Health Insurance Portability and Accountability Act. A/B MACs (A) or (HHH) processing institutional claims will create an ELGH record from the 270 to request this data from CWF and will receive the ELGA record from CWF in response. The A/B MAC (A) or (HHH) will create the 271 response or DDE screen from the ELGA transaction record. The response shows whether or not the beneficiary is currently in a home health admission period. If the beneficiary is not already under care at another HHA, he/she can be admitted to the inquiring HHA, and that agency will become primary. The beneficiary can also be admitted even if an admission period is already open at another HHA if the beneficiary has chosen to transfer. See chapter 31 for a description of the data elements and related requirements.