Notice of Termination/Revocation (NOTR)

20.1.2 - Notice of Termination/Revocation (NOTR) (Rev. 12847; Issued: 09-13-24; Effective: 06-03-24; Implementation: 10-07-24) NOTR is used when the hospice beneficiary is discharged alive from the hospice or revokes the election of hospice services. An NOTR should not be used when a patient is transferred. If a hospice beneficiary is discharged alive or if a hospice beneficiary revokes the election of hospice care, the hospice shall file a timely-filed Notice of Election Termination / Revocation (NOTR), unless it has already filed a final claim. A timely-filed NOTR is a NOTR that is submitted to the A/B MAC (HHH) and accepted by the A/B MAC (HHH) within 5 calendar days after the effective date of discharge or revocation. While a timely-filed NOTR is one that is submitted to and accepted by the A/B MAC (HHH) within 5 calendar days after the hospice election, posting to the CWF may not occur within that same timeframe. The date of posting to the CWF is not a reflection of whether the NOTR is considered timely-filed. In order for the NOTR to be accepted into the system, an election period must be established. If the notice of election, which creates the hospice election period is not submitted and posted before the NOTR, the NOTR will be rejected. Type of Bill Enter the appropriate 3-digit numeric type of bill code, according to the following code structure: 81B - Hospice (Non-hospital Based) NOTR 82B - Hospice (Hospital Based) NOTR Statement Covers Period (From-Through) • The hospice submits the From date on an NOTR differently in the following scenarios: When there is no change in the provider number during the election, the hospice must submit the start date of the election period as the From date on the NOTR. • If the revocation follows a transfer, the From date on the NOTR must match the START DATE2 on the benefit period that initiated the transfer. • If the revocation follows a change of ownership, the From date on the NOTR must match the OWNER CHANGE start date on the benefit periods. This process is to ensure that only the provider currently providing services to the beneficiary can submit the NOTR. In all cases, the Admission Date on the NOTR must match the From date. Patient’s Name The patient’s name is shown with the surname first, first name, and middle initial, if any. Patient’s Address The patient’s full mailing address including street name and number, post office box number or RFD, city, State, and ZIP code. Patient’s Birth Date Show the month, day, and year of birth numerically as MM-DD-YYYY. Patient’s Sex Show an “M” for male or an “F” for female. This item is used in conjunction with diagnoses and surgical procedures to identify inconsistencies. Admission Date The hospice enters the admission date, which must be the start date of the benefit period in all cases except when a transfer occurs. On a NOTR, the hospice enters the start date of the hospice benefit period in which the discharge or revocation is effective, not the initial hospice admission date. Show the month, day, and year numerically as MM-DD-YY. Facility Zip Code Enter the hospice's ZIP code (9-digit). The ZIP code entered must match the ZIP code in the Master Address field of the provider's address file. Condition Codes Condition codes are not required on an original NOTR. If the hospice is correcting a revocation date using occurrence code 56, the hospice reports condition code D0. If the two codes are not reported together, the NOTR will be returned to the hospice. Occurrence Codes and Dates Hospices may submit an NOTR that corrects a revocation date previously submitted in error. In this case, the hospice reports the correct revocation date in the Through Date field and reports the original, incorrect revocation date using occurrence code 56. Medicare systems use the original, incorrect date to find the election record to be corrected, then replaces that revocation date with the corrected information. If a revocation date was submitted entirely in error (for instance, the beneficiary actually transferred to another hospice, rather than revoking their hospice benefit), the hospice can remove the revocation date via Direct Data Entry by submitting TOB 8xB with zeroes in the Through date. The hospice reports the original, incorrect revocation date on the NOTR using occurrence code 56 and indicate the NOTR is a correction by adding condition code D0. Release of Information Valid values are: I- Informed consent to release medical information for condition or diagnoses regulated by Federal Statutes Y - Yes, provider has a signed statement permitting release of information. Provider Number The hospice enters their NPI. Medicare systems ensure that the provider number submitted on the NOTR is the currently active billing provider (e.g. the provider number matches that on the hospice election period or the most recent transfer date or change of ownership date on any benefit period). If any other provider number is submitted, the NOTR is returned. Insured’s Name Send all NOEs with Medicare as the primary payer. Enter the beneficiary’s name on line A. Show the name exactly as it appears on the beneficiary’s HI card. Insured’s Unique Identifier On the same lettered line (A, B, or C) that corresponds to the line on which Medicare payer information is shown enter the patient’s unique identifier by the health plan for the insured. For example, if Medicare is the primary payer, enter the MBI. To ensure accuracy and prevent a delay in the timely receipt or posting the hospice notice of election, hospices should validate this information using the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS). Only in the event that the HETS data is not available should the hospice show the number as it appears on the patient’s HI Card, Social Security Award Certificate, Utilization Notice, EOMB, Temporary Eligibility Notice, etc., or as reported by the SSO. Principal Diagnosis Code CMS accepts only HIPAA approved ICD-9-CM or ICD-10-CM/ICD-10-PCS codes, depending on the date of service. The official ICD-9-CM codes, which were updated annually through October 1, 2013, are posted at http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html The official annual updates to ICD-10-CM and ICD-10-PCS codes are posted at http://www.cms.gov/Medicare/Coding/ICD10/index.html Use full diagnosis codes including all applicable digits, up to five digits for ICD-9-CM and up to seven digits for ICD-10-CM. Attending Physician I.D. The hospice enters the name and provider identifier of the attending physician designated by the patient at the time of election as having the most significant role in the determination and delivery of the patient’s medical care. The patient’s designated attending physician could be an independent physician, hospice physician, a nurse practitioner, or physician assistant. If there is no attending physician listed, then the hospice shall report the hospice certifying/recertifying physician. Other Physician I.D. The hospice enters the name and provider identifier of the hospice physician responsible for certifying/recertifying that the patient is terminally ill, with a life expectancy of 6 months or less if the disease runs its normal course. For electronic claims, this information is reported in Loop ID 2310F – Referring Provider Name. NOTE: Both the attending physician and other physician fields should be completed unless the patient’s designated attending physician is the same as the physician certifying/recertifying the terminal illness. When the attending physician is also the physician certifying/recertifying the terminal illness, only the attending physician field is required to be populated, the other physician field would not need to be populated. Provider Representative Signature and Date A hospice representative must make sure the required physician’s certification, and a signed hospice election statement are in the records before signing the Form CMS-1450. A stamped signature is acceptable.