Claims From Medicare Advantage Organizations

30.4 - Claims From Medicare Advantage Organizations (Rev. 2258, Issued: 07- 29-11, Effective: 01-01-12, Implementation: 01-03-12) Federal regulations require that Medicare fee-for-service A/B MACs (HHH) maintain payment responsibility for managed care enrollees who elect hospice. These regulations are found at 42 CFR Part 417, Subpart P:go to http://www.gpo.gov/fdsys/browse/collectionCfr.action; select the applicable year, and scroll down to Part 417, and go to 42 CFR 417.585 Special Rules: Hospice Care (b); and also at 42 CFR 417.531 Hospice Care Services (b) which can be located in the same manner. Medicare Fee for Service retains payment responsibility for all hospice and non- hospice related claims beginning on the date of the hospice election. A. Covered Services While a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee-for-service A/B MAC (A), (B), or (HHH) of CMS. These claims are subject to the usual Medicare rules of payment, but only for the following services: 1. Hospice services covered under the Medicare hospice benefit if billed by a Medicare hospice; 2. Services of the enrollee’s attending physician if the physician is not employed by or under contract to the enrollee’s hospice; 3. Services not related to the treatment of the terminal condition while the beneficiary has elected hospice; or 4. Services furnished after the revocation or expiration of the enrollee’s hospice election until the full monthly capitation payments begin again. Monthly capitation payments will begin on the first day of the month after the beneficiary has revoked their hospice election. B. Billing of Covered Services Medicare hospices bill the Medicare fee-for-service A/B MAC (HHH) for beneficiaries who have coverage through Medicare Advantage just as they do for beneficiaries with fee-for-service coverage. Billing begins with a notice of election for an initial hospice benefit period, and followed by claims with types of bill 81X or 82X. If the beneficiary later revokes election of the hospice benefit, a final claim indicating revocation, through use of occurrence code 42, should be submitted as soon as possible so that the beneficiary’s medical care and payment is not disrupted. Medicare physicians may also bill the Medicare fee-for-service A/B MAC (HHH) for beneficiaries who have coverage through Medicare Advantage as long as all current requirements for billing for hospice beneficiaries are met. These claims should be submitted with a GV or GW modifier as applicable. A/B MACs (HHH) process these claims in accordance with regular claims processing rules. When these modifiers are used, A/B MAC (HHH) are instructed to use an override code to assure such claims have been reviewed and should be approved for payment by the Common Working File in Medicare claims processing systems. As specified above, by regulation, the duration of payment responsibility by fee-for- service A/B MACs (HHH) extends through the remainder of the month in which hospice is revoked by hospice beneficiaries. MA plan enrollees that have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee-for-service A/B MACs (HHH) as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked.