Home Health Beneficiary Eligibility and Transfers

Published 04/03/2025

The admission process is one of the most important steps in home health (HH) billing. Upon referral of HH admission, beneficiary eligibility shall be checked for current HH admissions, hospice elections and payor information such as Medicare Secondary Payer (MSP) information and Medicare Advantage (MA) plan enrollments. Preforming eligibility checks reduce billing errors, may avoid overlapping situations and loss of reimbursement.

You may check a beneficiary’s HH eligibility by using Palmetto GBA’s eServices portal or via a billing agencies, clearinghouses, or software vendor’s eligibility system. 

Eligibility Check Using eServices (User Manual linked in the Resources section below)

  • Log into eServices and select the Eligibility tab
  • Enter the required beneficiary data
    • To receive results, all information entered must match the beneficiary’s data maintained by Medicare
    • Important: Enter a date range to retrieve all eligibility information available. Not entering a date range will result missing or incomplete HH information being returned in the results.
      • Palmetto GBA recommends the last 24 months are entered
      • The system allows date requests up to four (4) years prior to, and four (4) months in the future of, the current date. Date ranges may not exceed 24 months at a time
  • Press Submit to start the query

If your query is successful, you will be presented with additional eligibility sub-tabs.

  • Select the Hospice/Home Health tab
    • The Home Health Care section provides information for each period start and end date, the beneficiary’s patient status, the serving HHA’s National Provider Identifier (NPI) and the corresponding billing activity dates
    • The Hospice section provides current and previous Medicare Benefit Hospice elections
    • Select the MSP tab — When a beneficiary has a primary payer other than Medicare, the MSP tab provides the beneficiary’s primary insurance information
    • Select Plan Coverage tab — The Plan Coverage tab provides information regarding the beneficiary’s enrollment under MA plans that provide Part A and B benefits for beneficiaries enrolled under a contract

Once you have accessed the beneficiary’s HH eligibility you are now ready to determine if the beneficiary is new to the home health benefit or is under an established home health plan of care in need of transferring from another home health agency (HHA). A transfer is described as a single beneficiary choosing to change HHAs. It is imperative that HHAs work together during a transfer situation.

  • If the latest HH period displayed has a Patient Status "30," this indicates the beneficiary is currently under an established plan of care with another HHA and a transfer would need to occur
    • HH periods display the National Provider Identifier (NPI) of the HHA for each period. You may use the "Search NPI Registry" function of the NPPES website to receive the name and contact information of the HHA
  • If a beneficiary-elected transfer takes place be sure to contact the current HHA to agree upon a transfer date and avoid a dispute between the agencies

Steps for the Receiving HHA

  • The receiving HHA identifies a Patient Status of "30" on the latest HH period available in beneficiary’s HH eligibility record. Therefore, regardless of whether the receiving agency is admitting a beneficiary outside of the period currently reflected in the beneficiary’s HH eligibility, the transfer requirements apply
  • The receiving HHA must document that the beneficiary has been informed that the initial HHA will no longer receive Medicare payment on behalf of the patient and will no longer provide Medicare covered services to the patient after the date of the patient's elected transfer in accordance with current patient rights requirements at 42 CFR 484.50(d)
    • The receiving HHA must also document in the record that it accessed the Medicare contractor’s inquiry system to determine whether the patient was under an established home health plan of care, and it must contact the initial HHA on the effective date of transfer.
  • Contact the initial HHA to agree on a transfer date
    • Document you contacted the other agency and include who you talked to at the agency, date and time contacted

Steps for the Transferring HHA

  • Document the receiving agency contacted you to inform you of the beneficiary transfer and that you accepted the transfer
  • Include the name of the person you spoke with at the agency, date, time and date agreed upon for the transfer to take place
  • Submit your final claim with Patient Status Code "06" to indicate transfer to another HHA. This will result in a partial payment adjustment. The partial payment adjustment is a proportion of the period payment and is based on the span of days including the start-of-care date (for example, the date of the first billable service) through and including the last billable service date under the original plan of care before the intervening event, such as a transfer. 

Processing Overlapping HH Periods

The Medicare claims system is programmed to allow a Notice of Admission (NOA) which overlaps a previously established period. As a result, the previously established period is shortened and a new period is created, allowing the overlapping NOA to be paid.

  • Medicare will allow an NOA (Type of Bill 32A) to overlap an existing HH period or open admission if condition code (CC) 47 is present on the NOA. CC 47 may also be used when the beneficiary has been discharged from another HHA, but the period of care claim has not been submitted or processed at the time of the new admission to discharge the beneficiary.
  • Medicare will allow an NOA to overlap an existing HH period record without condition code 47 if the CMS Certification Number (CCN) on the NOA and the period match

Hospice Election Overlap

If a beneficiary’s eligibility displays a current Medicare Benefit Hospice election, the HHA will need to contact the hospice to verify if the beneficiary has revoked the hospice benefit, but the hospice has not submitted discharge information to Medicare. 

A beneficiary receiving hospice and HH benefits at the same time would be rare, as electing the hospice benefit is palliative rather than curative nature of treatment. Additionally, any Medicare services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition, is only payable to the hospice. The hospice would have to approve and coordinate all care related to the treatment of the terminal condition or a related condition.

Resources


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