Palmetto GBA Releases Ask-the-Contractor Teleconference Q&As

Palmetto GBA representatives held an Ask-the-Contractor teleconference on July 10 to discuss multiple provider issues, including version 5010 news and updates. Palmetto staff also answered the following provider questions:

Question: A written election to remain under the streamline methodology must be submitted no later than 60 days after the receipt of the 2012 cap determination letter. Could you please provide some guidance regarding when we should expect to receive the 2012 cap determination letter so that we don’t inadvertently miss the specified deadline regarding the streamline methodology?

Answer: Technical Direction Letter (TDL) 12330 states that all hospice cap calculations for the cap year ending on October 31, 2011, shall begin no earlier than November 2012 and shall be completed and demands issued no later than March 31, 2013. Therefore, 2012 cap determination letters will be issued sometime around March 2013 or later.

Question: When a patient moves over to an HMO, if the HMO eligibility begins July 1 and we cut off our episode on that same day, are we supposed to make our end of episode date be the date prior to the actual HMO start date? In this example instead of our end of home health episode being July 1, it would change and be June 31 since the patient started the HMO effective July 1.

Answer: When a patient that is receiving the Medicare home health benefits elects HMO coverage during a home health episode, the home health agency (HHA) must discharge the patient from Medicare services before the effective date of the HMO plan and use a 06 patient status code on that discharge claim. Regardless of when your episode end date would normally occur, you would need to discharge the patient prior to the effective date of the HMO election.

You may find information on home health patients transitioning from and/or to HMOs, including how to handle the OASIS assessments, in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 10, Sections,, and 80. For more information regarding OASIS requirements, you would need to contact your OASIS Education Coordinator. The names and addresses for the OASIS Coordinators are located on the CMS Web site at

Question: I have a question about 5010 enrollment. If we submit our claims through a clearing house and they are approved to submit 5010, does the provider also need to contact your EDI to get enrolled for 5010?

Answer: If your clearing house, the vendor that you are working with, is already able to submit claims in 5010 and they submit the claims on your behalf, then you do not need to contact EDI separately to get set up for 5010.


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