Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Home Health Agency Bulletin 48 September 2012 TO: Home Health Agency Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Introduction of the New Homebound Assessment Form Background MassHealth has developed the attached Homebound Assessment (HA) Form for use by home health agency (HHA) providers under the following circumstances: * after MassHealth has sent the HHA provider a notice to demand bill Medicare; and * the provider has reason to believe that a MassHealth dually eligible member is not eligible for Medicare reimbursement for HHA services; and * the MassHealth member is not homebound (as defined by the Social Security Act - Sec. 1814(a). and §1835(a). [42 U.S.C. 1395f(a) and 1395n(a)]). Homebound Assessment Form Through third party liability (TPL) review MassHealth identifies paid claims for HHA services that have the potential for Medicare coverage, and then notifies HHA providers to demand-bill Medicare. An HHA provider may use the HA Form only when MassHealth has sent a notice to that provider to demand-bill Medicare. This form offers the HHA provider a more efficient means to demonstrate to MassHealth that a member is not homebound and does not meet the Medicare coverage criteria. If MassHealth determines, based on the information submitted on the HA form, that the member is not homebound, MassHealth will instruct the HHA provider that it is not required to demand-bill Medicare. If MassHealth determines that the member is homebound, MassHealth will instruct the provider to demand-bill Medicare. (continued on next page) MassHealth Home Health Agency Bulletin 48 September 2012 Page 2 Homebound Assessment Form (cont.) HHA providers should send or attach additional supporting documentation to the form to demonstrate that the member is not homebound, including a physician’s plan of care (or clinical notes to support the plan of care). Any other documentation must be limited to the clinical documentation only. Please Note: The use of the HA Form is voluntary. If the provider chooses not to submit the HA Form, it must demand-bill Medicare in accordance with the notice. The HA Form is available online at www.mass.gov/masshealth. Scroll to the bottom of the page and click on MassHealth Provider Forms in the lower right-hand panel. Scroll down the page to the section titled Home Health Agency. The provider must submit the HA Form electronically (see page 3 of the form for further submission instructions). Questions If you have any questions about the information in this bulletin, please contact the Medicare Appeals Customer Service at 1-877-533-4381, or e-mail your inquiry to hhmedicareappealshomebound@umassmed.edu. THE COMMONWEALTH OF MASSACHUSETTS Executive Office of Health and Human Services Home-Bound Assessment Form Please complete each part of this form. All information is required. Incomplete forms will not be accepted. SECTION I Provider Name: MassHealth Provider ID: Patient Name: MassHealth Member ID: Dates of Service: SECTION II Please check one or more of the following statements that indicate why the patient is not homebound as defined by Social Security Act - Sec. 1814(a). and §1835(a). [42 U.S.C. 1395f(a) and 1395n(a)]. Identify or explain the general reason the patient is not homebound. Select one of the common statements provided below, or state the reason that the patient is not homebound under “Other.” Physician did not certify the patient is confined to his or her home. Patient is able to leave home without a considerable and taxing effort. Patient leaves the home for long periods, other than for medical treatment, religious services, or the trip is infrequent/occasional. Patient does not have an illness or injury that restricts his or her ability to leave home. Other SECTION III Attach copies of clinical records that indicate the patient is not homebound as defined by Social Security Act - Sec. 1814(a). and §1835(a). [42 U.S.C. 1395f(a) and 1395n(a)]). Select the type of documentation that will be submitted as evidence to support the homebound status of the given patient. If the type of documentation is not listed, select “Other,” and then provide a brief description of the document type. Plan of Care (485/487) Physician Orders Skilled Nursing/Therapy Notes Outcome and Assessment Information Set (OASIS) MD Face-to-Face Certification Other _______________________________________________________________ SECTION IV Please provide any additional information that may be relevant to the issue of whether this patient is homebound as defined by Social Security Act - Sec. 1814(a). and §1835(a). [42 U.S.C. 1395f(a) and 1395n(a)]). Any additional information relevant to the patient’s homebound status should be included in this section. This section may be left blank if the supporting documentation provides a full description of homebound status. SECTION V – Provider of DME Attestation, Signature, and Date I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have provided has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I also certify that I am the provider or, in the case of a legal entity, duly authorized to act on behalf of the provider. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein. Provider’s signature (Signature and date stamps, or the signature of anyone other than the provider or a person legally authorized to sign on behalf of a legal entity, are not acceptable.): Printed legal name of provider: Printed legal name of individual signing (if the provider is a legal entity): Date: ________________ HBA (09/12) Instructions for Submitting the Homebound Assessment Form 1) Send a general request e-mail to hhmedicareappealshomebound@umassmed.edu. This e-mail should state that you are requesting a secure connection to transmit a homebound assessment form. 2) You will receive instructions from MassHealth about the secure e-mail connection. Please wait until you receive this information. Do not send any documentation directly to the above e-mail address, as they will not be secure. After you have received the first secure transmission e-mail from MassHealth, you are then set up to send all future documents via the secure e-mail system. 3) Using the secure e-mail connection, submit the completed HA Form and supporting documentation to MassHealth. In addition, MassHealth has the capability of accepting the HA Form and supporting documentation through a secure FTP connection. If you would prefer to use this transmission method, please send an inquiry e-mail to hhmedicareappealshomebound@umassmed.edu. Required Timeframes for Response MassHealth will respond within 10 business days of receipt of the HA Form and supporting documentation. MassHealth will provide a response for each case, via the secure e-mail connection. Please note: Your agency may still be required to submit a demand bill to Medicare upon MassHealth review. To ensure that timely Medicare filing requirements are adhered to, please consider the above 10 business-day time limit into your agency’s ability to file a claim to Medicare. MassHealth will not expedite any reviews due to timely filing concerns.