Hospice providers now may submit claims to Medicare Advantage Organizations

July 12, 2021 ABILITY

More Medicare beneficiaries may enter hospice care with complementary Medicare Advantage (MA) plans as the Centers for Medicare & Medicaid Services (CMS) rolls out health plan innovations under the Medicare Advantage Value-Based Insurance Design (VBID) Model. The innovative plans are meant to reduce costs and improve care for Medicare beneficiaries.

Once hospice providers have registered with CMS to participate in the program, they can begin identifying eligible patients and can bill the appropriate Medicare Advantage Organization (MAO) by first submitting a notice of election (NOE).

Identifying hospice patients with MA coverage

To take advantage of VBID coverage, hospice providers first must determine if patients with Medicare coverage also are beneficiaries of an eligible MA program. Patients who present a Medicare card with a Medicare Beneficiary Identifier can check eligibility using their normal processes or by utilizing the MAC Portal, the MAC Interactive Voice Response System, the Health Insurance Portability and Accountability Act Eligibility Transaction System (HETS), billing agencies, clearinghouses or software vendors.

The same resources can be used for beneficiaries whose cards do not list a Medicare Beneficiary Identifier by using the MA contract number and plan benefit package identification information on the MA enrollment card.1

Submitting claims to participating MAOs

To be paid at original Medicare rates for eligible patients, hospice providers that are not contracted with participating MAOs first must submit original Medicare claims for the covered hospice care.

To begin a bill for an eligible patient, provider must confirm that the hospice start date was on or after Jan. 1, 2021, and file a NOE with the provider’s MAC and the participating MAO. Next, claims should be submitted to MAC following normal procedures. Those claims will be returned with the following message:

  • Claim Adjustment Reason Code (CARC) 96: Non-covered charge(s)
  • Remittance Advice Remark Code (RARC) MA73: Information remittance associated with a Medicare demonstration. No payment issued under Fee-for-Service Medicare as patient has elected managed care
  • Group Code Contractual Obligation (CO): MAOs participating in the VBID Model’s hospice benefit component will be responsible for coverage of the above services

The claim also must be submitted to the MAO. Hospice providers that already are contracted with the participating MAO should follow the contractual billing and claims-processing guidelines. Providers that are not in the MAO’s network can use the same forms they use to submit claims to their MAC. Once the patient is discharged from hospice, or the benefit is revoked, the provider needs to file a Notice of Termination or Revocation with the provider’s MAC and the patient’s MAO.

Hospice providers who use ABILITY EASE All-Payer will not see a change in claims submissions, as a MAO is treated similarly to a secondary payer. ABILITY EASE All-Payer users already are able to submit NOEs to MAOs.

To register or to get more information on the VBID program, visit the CMS website. If you have any questions about how to submit VBID claims within your claims system, reach out to an ABILITY expert for guidance.

1. “VBID Model Hospice Benefit Component Billing & Payment: CMS Innovation Center.” Innovation Center. Centers for Medicare & Medicaid Services, October 28, 2020. https://innovation.cms.gov/innovation-models/vbid-hospice-benefit-billing-payment.

ABILITY and design®, ABILITY® and ABILITY EASE® are trademarks of ABILITY Network, Inc.

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