Interpreting the Part A Home Health Teaching and Instruction for Providers (TIP) Letter
Provider education is one of the primary goals of Palmetto GBA. To help achieve this goal, the Part A Medical Review Department at Palmetto GBA developed an educational tool known as TIP Letters for each line of business, including Home Health, Hospice, Part A SC, and Outpatient Home Health (34X bill type). The purpose of these monthly letters is to furnish information to providers, for which Palmetto GBA is the fiscal intermediary, regarding claims denied by medical review and suggestions to avoid the recurrence of these denials. The letters are for educational purposes only. They do no reflect the charge denial rate or the total number of claims billed by a provider for the specified month/year. The letters will not reflect any denials that have been adjusted or overturned in the re-open or redetermination process.
Claim Criteria:
The information included in the TIP letter is based on the outcome of the initial determinations or adjustment of denials for reason code 56900 for all claims that meet the following criteria:
1. Billed by Home Health providers participating in the Medicare program and received at least two denials and/or an adjustment to deny after an initial 56900 denial processed during the specified month/year,
2. Selected for medical review (For more information regarding the claim selection process, refer to the article, “The Providers Flowchart To Progressive Corrective Action” on the Palmetto GBA Web site, http://www.PalmettoGBA.com.
3. Finalized in the reporting month/year.
Types of TIP Letters:
The provider may receive one of three Home Health TIP Letters depending upon the denial reason(s) for the letter.
1. Letter One: Two or more denied claims processed during a specified month/year,
2. Letter Two: One or more denied claims processed during a specified month/year after an initial 56900 denial, or
3. Letter Three: Two or more denied claims processed during a specified month/year, and one or more denied claims processed during a specified month/year after an initial 56900 denial.
Interpretation of the Information Contained in the TIP Letters:
The following information includes detailed instructions on how to interpret the facts included in the Part A Home Health TIP Letters.
Letter One: Two or more denied claims processed during a specified month/year
This TIP Letter includes the following information for each provider with two or more denied claims processed during a specified month/year:
- SUBJECT - Medicare Home Health Services Non-covered (Denied) on Claims Processed in Month/Year
- The reason the letter is being sent
- A table listing the individual statistics for the specified provider as follows:
- Number of total claims reviewed for your agency
- Number of total claims denied for your agency
- Rank of provider*
- Percentage of Claims with denials of those reviewed for your agency
- Average Percentage of claims denied of those reviewed for all providers
- Number of home health providers who participate in the Medicare program and received medical review denials
* Rank of the provider = the provider’s position in descending order based on the following calculation: (number of total claims denied for your agency) divided by (number of total claims reviewed for your agency) X 100 = percentage of claims denied of those reviewed for your agency. NOTE – A ranking of #1 indicates that the provider has the highest percentage of denials on claims reviewed out of all providers meeting the stated criteria.
- A list of all denial reason codes in the reporting month/year for the specified provider, as well as a description of the denial reasons
- A detailed explanation of the denials, up to three denial reasons listed
- Suggestions to avoid future denials for the reasons listed
- A list of references with more information regarding the top denial reasons listed
Reports Enclosed – Letter One
Two provider-specific reports and one graph are enclosed with each TIP letter on two or more denied claims processed during a specified month/year.
1. The title of the first report is as follows: Summary of Home Health Claims with Medical Review Denials by Provider and Rank of Denial Code Group On Part A Home Health Claims Processed by Palmetto GBA in Month/Year. A sample of this report is attached for reference. This report includes the following:
- Provider ID - Provider’s Medicare Identification number
- Provider Name – Name of the provider
- Total Claims Reviewed - Total number of claims reviewed for the specific provider
- Total Claims Denied – Total number of claims denied for the specific provider
- Rank of Denial Code Group for Provider - The provider-specific ranking of their denial reason(s) based on the frequency that they occur
- Denial Code Group – The denial code(s) that indicate the reason(s) for which each claim denied.
- Denial Code Description – Brief description of denial reason(s) for which each claim denied.
- Total Denial Code Claims – The total number of denials for each denial code
2. The title of the second report is as follows: Listing of Home Health Claim Lines with Medical Review Denials by Provider, HICN, DCN, and Line Number On Part A Home Health Claims Processed by Palmetto GBA in Month/Year. A sample of this report is attached for reference. This report includes the following:
- Provider ID - Provider’s Medicare Identification number
- Provider Name – Name of the provider
- HICN – Health Insurance Claim Number issued to Medicare patients to identify entitlement to Medicare benefits
- Patient Name – The name of the patient for which the claim was billed
- DCN (Document Control Number) – A unique identification number assigned to each claim when it is received by Palmetto GBA for processing
- Bill Type – 32X and 33X home health type of bill
- From Date – The beginning date of service for the claim
- Process Date – The date the claim is finalized by the processing system
- Rev. Code - The four digit revenue code for the HIPPS Code, each discipline, and visits billed by the provider
- HIPPS Code – Health Insurance Prospective Payment System Code
- Original HIPPS Code – The HIPPS Code billed for the episode period
- Line Number – The number of the claim line which is denied (as seen in Direct Data Entry)
- Service Date – The date for which services are rendered and billed by the provider
- Denial Code Group – The denial code(s) for each claim denied
3. A graph is enclosed that includes a bar chart identifying the following (attached is a sample graph for reference):
- Percentage of Claim With Denials of those Reviewed
- Average Percentage of Claims Denied of those Reviewed for All Providers
Letter Two: One or more denied claims processed during a specified month/year after an initial 56900 denial.
This TIP Letter includes the following information for one or more denied claims processed during a specified month/year after an initial 56900 denial:
- “SUBJECT”- Medicare Home Health Services Non-covered (Denied) on Claims Processed in Month/Year, after an Initial 56900 Denial.
- The reason the letter is being sent
- A table listing the individual statistics for the specified provider as follows:
- Number of total claims reviewed after an initial 56900 denial
- Number of total claims denied after an initial 56900 denial
- Rank of provider (refer to Letter One for more information)
- Percent of claims denied to claims reviewed
- Number of home health providers who participate in the Medicare program and received medical review denials
- A list of all denial reason codes in the reporting month/year for the specified provider, as well as a description of the denial reasons
- A detailed explanation of the denials, up to three denial reasons listed
- Suggestions to avoid future denials for the reasons listed
- A list of references with more information regarding the top denial reasons listed
Reports Enclosed – Letter Two
Two provider-specific reports are enclosed with each TIP letter on denied claims processed during a specified month/year after an initial 56900 denial.
1. The title of the first report is as follows: Summary of Home Health Claims with Medical Review Denials by Provider and Rank of Denial Code Group On Adjusted Claims Reviewed after an Initial 56900 Denial On Part A Home Health Claims Processed by Palmetto GBA in Month/Year. A sample of this report is attached for reference. This report includes the following:
- Provider ID - Provider’s Medicare Identification number
- Provider Name – Name of the provider
- Total Claims Reviewed - Total number of claims reviewed for the specific provider in the specified month/year
- Total Claims Denied – Total number of claims denied for the specific provider in the specified month/year
- Rank of Denial Code Group for Provider - The provider-specific ranking of their denial reasons based on the frequency that they occur
- Denial Code Group – The denial code(s) that indicate the reason for which each claim denied.
- Denial Code Description – Brief description of denial reason for which each claim denied
- Total Denial Code Claims – The total number of denials for each denial code
2. The second report is titled, Listing of Home Health Claims with Medical Review Denials by Provider, HICN, DCN, and Line Number On Adjusted Claims Reviewed after an Initial 56900 Denial On Part A Home Health Claims Processed By Palmetto GBA in Month/Year. A sample of this report is attached for reference. This report includes the following:
- Provider ID - Provider’s Medicare Identification number
- Provider Name – Name of the provider
- HICN - Health Insurance Claim Number issued to Medicare patients to identify entitlement to Medicare benefits
- Patient Name – The name of the patient for which the claim was billed
- DCN - (Document Control Number) – A unique identification number assigned to each claim when it is received by Palmetto GBA for processing
- Bill Type – 32X and 33X home health type of bill
- From Date – The beginning date of service for the claim
- Process Date – The date the claim is finalized by the processing system
- Rev. Code – The four digit revenue code for the HIPPS Code, each discipline, and visits billed by the provider
- HIPPS Code – Health Insurance Prospective Payment System Code
- Original HIPPS Code – The HIPPS code billed for the episode period
- Line Number – The number of the claim line which is denied (as seen in Direct Data Entry)
- Service Date – The date(s) for which services are rendered and billed by the provider
- Denial Code Group - The denial code(s) that indicate the reason for which each claim denied
Letter Three: Two or more denied claims processed during a specified month/year, and one or more denied claims processed during a specified month/year after an initial 56900 denial.
This TIP Letter includes the following information for each provider with two or more denied claims processed during a specified month/year, and one or more denied claims processed during a specified month/year after an initial 56900 denial:
- The provider name and number
- SUBJECT - Medicare Home Health Services Non-covered (Denied) on Claims Processed in Month/Year, Including Denials Received after an Initial 56900 Denial.
- The reason the letter is being sent
- The combined information as indicated in Letter One and Letter Two
These letters include a reminder that Part A Home Health TIP Letters are to be used for educational purposes only. A TIP Letter is not a denial notification for appeals purposes. Please refer to the Remittance Advice (RA) for denial notification.