Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Home Health Agency Bulletin 46 January 2009 TO: Home Health Agencies Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: New Home Health Coverage Determination Form Background MassHealth is implementing a new Home Health Coverage Determination Form. This form is accessible and is fillable online on the MassHealth Web site. This form must accompany all commercial coverage determinations, or Explanations of Benefits (EOBs), submitted to MassHealth. For more information, please refer to Transmittal Letter HHA-33 (June 2002) and Home Health Agency Bulletin 41 (November 2003). Please note that this bulletin transmits modifications to the qualifying event definitions. For members that have both commercial insurance and MassHealth, providers must submit a coverage determination from the primary insurer any time the member’s medical condition, resulting in a change of skilled services in the plan of care, or health-insurance-coverage status changes. Submitting Claims MassHealth does not accept annual EOBs for services denied by to MassHealth the commercial insurer. MassHealth is always the payer of last resort. Home health providers must bill, obtain, and send an EOB from the primary insurer whenever the member has a qualifying event. Providers must submit a copy of the EOB to MassHealth within 10 days of receiving notification of denial from the insurer. Providers must continue to submit paper coverage determinations for all qualifying events, whether billing electronically or on paper. Third-Party Liability Billing requirements are contained in MassHealth’s third-party liability Requirements (TPL) regulations at 130 CMR 450.316 and 450.317. Qualifying Event A qualifying event is defined as any change in a member’s condition or circumstances, including a change in health insurance plans that may trigger a change in insurance coverage. The following list includes some examples of qualifying events that require a provider to request coverage and obtain an Explanation of Benefits (EOB) from a commercial insurer. (continued on next page) Qualifying Event Qualifying/triggering events include, but are not limited to the following: (cont.) • a new admission to a home health agency (HHA); • a readmission to HHA after a discharge from an inpatient hospital or skilled facility stay; resulting in a change of skilled services in the plan of care; • cessation of commercial insurance coverage or change of insurance (Complete and submit a TPLI form with the EOB and new Home Health Coverage Determination Form.); • exhaustion of annual commercial insurance coverage or other periodic benefit(s); • reinstatement of insurance benefits; • change in the patient’s medical condition resulting in a change of skilled services in the plan of care. Submitting Home Submit a completed Home Health Coverage Form with every coverage Health Coverage determination. It can be faxed to 617-886-8133 or mailed to the following Determination Forms address. MassHealth Home Health Claims The Schrafft’s Center 529 Main Street, 3rd Floor Charlestown, MA 02129 MassHealth’s Right MassHealth reserves the right to appeal any insurer’s denial of coverage to Appeal and Audit if it determines that the service may be covered under the member’s insurance policy. Providers must, at MassHealth’s request, submit the claim and related clinical or service documentation to MassHealth or to an insurance carrier, or both, if MassHealth determines that the provider’s submission is needed for MassHealth to exercise this right of appeal. MassHealth also reserves the right to perform audits to ensure compliance with all TPL regulations. Providers must, at MassHealth’s request, submit the requested documentation to MassHealth in order to substantiate the service(s) provided to the member, in accordance with 130 CMR 450.205. (continued on next page) Requesting a A copy of the Home Health Coverage Determination Form is attached. It Supply is accessible on the MassHealth Web site at www.mass.gov/masshealth by clicking on the link for MassHealth Provider Forms in the lower right corner of the page. Requests for paper copies of this form must be submitted in writing and faxed to 617-988-8973 or mailed to the following address. MassHealth ATTN: Forms Distribution P.O. Box 9118 Hingham, MA 02043 Questions If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. . The Commonwealth of Massachusetts Executive Office of Health and Human Services www.mass.gov/masshealth Home Health Coverage Determination Form (Attach EOB from primary insurer to this form.) HHCD-1 (01/09) Date: Member Name: Member ID: Diagnosis: Dates of Service: to Services Provided (Check all that apply.): Skilled Nursing Continuous Skilled Nursing Physical Therapy Occupational Therapy Speech/Language Pathology Home Health Aide Qualifying/Triggering Event (Check one.): New admission to a home health agency (HHA) A readmission to an HHA after a discharge from an inpatient hospital or skilled facility stay; resulting in a change of skilled services in the plan of care Cessation of commercial insurance coverage or a change of insurance (attach a completed TPLI form) Exhaustion of annual commercial insurance coverage or other periodic benefit(s) Reinstatement of insurance benefits Change in the patient’s medical condition resulting in a change of skilled services in the plan of care Please provide a brief description of change: Is this a personal injury protection (PIP) case? yes no Are you covending? yes no If yes, name of covendor: Provider Name: Provider Address: Branch Address: Contact Name: Contact Phone/Fax No.: MassHealth Provider No.: NPI: Send to: MassHealth Home Health Claims The Schraffts Center 529 Main Street, 3rd Floor Charlestown, MA 02129 Fax: 617-886-8133 Purpose of Home Health Coverage Determination (HHCD) Form The MassHealth HHCD Form is used by home health agencies to show compliance with MassHealth’s third-party liability (TPL) regulations (130 CMR 450.316 and 450.317). For members with commercial insurance in addition to MassHealth, providers must submit claims to the commercial insurer for a coverage determination before submitting the claim to MassHealth. Coverage determinations and explanations of benefits (EOBs) must be obtained whenever a member has a qualifying event. The HHCD Form must accompany the coverage determination and/or EOB to MassHealth within 10 days of the provider’s receipt of the EOB. Home health providers must continue to submit paper coverage determinations for all qualifying events whether billing electronically or on paper. Instructions for Completing the HHCD Form Provider Information: Fill in your provider name, branch address, and contact’s phone and fax numbers. MassHealth Provider No.: Fill in your MassHealth provider number. NPI: Fill in your national provider identifier (NPI) number. Date: Fill in the date you are sending the form and accompanying EOB to MassHealth. Member Name: Fill in the member’s name. Member ID: Fill in the member’s ID number. Diagnosis: Fill in the diagnosis/diagnoses; ICD-9 codes are not necessary. Dates of Service: Fill in the dates you want MassHealth to start and end payment. If there is no end date, enter a start date and indicate “ongoing.” Services Provided: Check off all services the agency is providing to the member. Qualifying/Triggering Event: Check off the reason the provider obtained the initial EOB or new EOB. If you are notifying us of a change in insurance, please complete both the HHCD Form and the TPLI form and send both with the EOB. Both forms are accessible from the MassHealth Web site at www.mass.gov/masshealth by clicking on the link for MassHealth Provider Forms in the lower right corner of the page. Description of Change: Indicate why the primary insurance company was billed.