Hospice Coalition Questions and Answers: June 5, 2025
To: Hospice Coalition Members
From: Palmetto GBA Provider Outreach and Education (POE)
Date: June 5, 2025
Reports
Questions for Response
Provider Enrollment
- Question: Hospices continue to experience delays in processing CMS-855A applications, whether a change in address, processing a change of ownership (CHOW) or other reasons. The “Provider Enrollment Processing Delay Important Update” on the website acknowledges the delays.
Question 1a: Can you provide insight into when the backlog may be cleared such that processing times may normalize?
Answer: We expect to clear up the backlog by October 2025.
Question 1b: The Important Update states to use the Provider Enrollment Status Lookup tool, but in some cases that doesn’t return any information or returns outdated information not related to the current application pending.
Answer: The Important Update states to use the Provider Enrollment Status Lookup tool, but in some cases that doesn’t return any information or returns outdated information not related to the current application pending.
Medical Review
- Question: We are aware that Palmetto GBA’s Medical Review team is quite busy. Once all claims selected for a Targeted Probe and Educate (TPE) audit are processed and either paid or denied, how long should a provider expect to wait to receive the Notice of Review Results after the Redetermination phase has been completed? Or is there another trigger for considering the TPE complete?
Answer: A detailed results letter is sent to the provider at the conclusion of each round with their Charge Denial Rate (CDR) and Claim Line Denial Rate (CLDR). Favorable appeal results prior to the results letter issuance would be calculated in the denial rates in the letter.
If a provider receives favorable appeal decisions after the issuance of the letter and those results bring both the CDR and CLDR below the 20-percent thresholds, the provider may request denial rate recalculations during the post-probe education session or via the Provider Contact Center. If the recalculation brings the provider below both rate thresholds, the provider may be removed from that specific TPE edit.
Reminders:
- A provider should not request a recalculation prior to receiving their results letter. Fully favorable appeal results will be calculated into the letter denial rates when issued.
- Recalculations should only be requested if the provider’s threshold is above the 20-percent CDR and CLDR thresholds, but favorable appeal results will take them below the thresholds
- Partial denials and down coding of services are included in the CLDR and continue to count as a claim paid in error. A claim must have no errors to not be calculated in the denial rates.
- Providers can calculate their CLDR using the Charge Denial Rate Calculator located under the Tools topic of the website
- Question: Some hospices report they are not receiving their Claim Review Determination Letters for TPE audits and only learn through the claims processing if the review was favorable or not. Can the determination letters be placed in eServices so hospices can receive and retrieve them timelier?
Answer: We recently had an issue with addresses for the providers when generating letters. As we come across letters with bad addresses, we are getting them reissued. For a letter to be delivered via eServices, the provider’s eServices Administrator must select the option for eDelivery.
- Question: Can Palmetto GBA begin to provide some patient-specific information for claim denials? The Review Determination Letters and the claim remarks in Direct Data Entry (DDE) give only the denial reason code and a generic statement such as documentation not supporting eligibility with references to Palmetto GBA and/or CMS materials. Hospices need additional information to understand denials, especially when they are quite surprised that the claim was denied. In the not too distant past, there was some specific information in DDE, but that has stopped. Even though they were limited, those DDE remarks were helpful to providers unlike the generic decision notices that have only a denial reason code.
We expect that a reviewer has to document the denial reason somewhere in the system. Why can that not be added to DDE? It is our understanding that Palmetto GBA provides what CMS has approved, and CMS would have to approve of any changes. But we see other MACs providing information that is specific to a patient (example below). Can Palmetto GBA ask CMS for approval to provide patient specific information?
Another MAC’s Denial Letter: “Reviewer Comment: (Deny) all charges: The documentation did not support a trajectory of terminal decline. The patient’s vital signs were stable. The patients weight/MAC was stable. Eating 25–50 percent of meals. There were no intractable infections such as pneumonia, sepsis, or ongoing fevers not responding to treatment. Ativan used PRN for symptom management. The patient’s skin was intact, and there were no stage 3–4 wounds. PPS remains 30–40 and FAST 7D. The documentation did not support terminal decline, and the patient’s care needs appeared to be chronic and custodial in nature. Refer to IOM 100-02, Chap 9, § 10. LCD L34538.”
Answer: We are limited with the amount of space we have for entering comments in the system. Team members are compiling a list of comments to submit to CMS for approval to add to what providers see in DDE and on the letters.
- Question: By their design, TPE audits are supposed to be about educating providers to ensure services and claims are compliant with regulations and policies. But hospices are not finding the post-TPE education calls to be very helpful because the POE representative’s information is generic and not individualized. The representatives are not involved in the reviews and have minimal patient-specific information.
We ask that Palmetto GBA review and enhance the information to provide patient-specific information. Can someone involved in the actual reviews participate in the education calls? Or can the reviewer provide written notes for the educator to reference?
Answer: As of January 2025, the process is as follows: Senior Provider Education Consultant reviews the patient specific denial information documented by the Medical Reviewer and discusses that on the final education calls. While not every claim denied is discussed, a cross-section of those denied for the same reason is sampled. The floor is then opened to the provider to ask any patient specific questions they may have to help them better understand the reason for the denial as well as if they are able to provide any additional information to assist with the appeals process. We are confident this will provide the patient specific information referenced in this question.
- Question: Please discuss findings to date with the Beneficiary Sharing TPE from the perspective of what you are learning about transfers of patients between hospices. Since the ADRs are for prepayment claims, we understand that they are random pulls and very few shared beneficiary scenarios are included. The article online, Pre-Payment Review Results for Beneficiary Sharing Hospice for Targeted Probe and Educate (TPE) for January through March 2025, showed edit effectiveness for only 2 providers. For other TPEs completed since then, are the reviews yielding insight into the reasons for transfers? Have any concerning practices been noted?
Answer: We are still gathering data and unable to provide any insight at this time.
- Question: We want to follow up on Question 6c from the March 6, 2025, Coalition Meeting addressing situations when a community attending physician gives a verbal certification and the hospice documents that, but the physician later either declines to sign or cannot be reached after numerous attempts.
Question 7a (March 6, 2025): Or if the patient agrees to a change in attending in writing before the hospice submits the first claim and opts for a hospice attending physician, would that obviate the need for a signed CTI by the community attending and there be no billing issues?
Answer: The attending must sign or a signed change in designated attending physician statement must be completed by the patient. The effective date for the change should be on the signed statement. CMS IOM 100-02, Chapter 9, Section 40.1.3.1 (PDF) states, "The statement must include the date the change is to be effective, the date that the statement is signed, and the patient’s (or representative’s) signature, along with an acknowledgement that this change in the attending physician is the patient’s (or representative’s) choice. The effective date of the change in attending physician cannot be earlier than the date the statement is signed.
"The date the change in designated attending physician statement is signed is the date that the Certification of Terminal Illness (CTI) is valid, so it depends on when that was signed by patient (or representative). CTI from community attending is not necessary but could affect billing based on date signed.” The last sentence above states that, “CTI from community attending is not necessary but could affect billing based on date signed.”
Question 7b: What does that sentence mean as far as an attending CTI not being needed? in what situation would it be acceptable for there not to be an attending CTI?
Answer: If the hospice cannot obtain written certification within 2 calendar days from the individual’s attending physician, it must obtain oral certification within two calendar days. The oral certification is placeholder for the individual’s attending physician’s written certification, or a partner of that physician. If the written is not received from the individual’s attending physician, the certification requirements are not met.
Question 7c: How do we properly submit a claim from the start of care date knowing that some days of care will not be reimbursed due to the attending physician not signing the CTI initially
Answer: Written certifications with the signature(s) of the physician(s), the date signed, and the benefit period dates that the certification or recertification covers must be on file in the hospice patient’s record prior to submission of a claim to the Medicare contractor. If the initial CTI is not completed, the services are not billable since the Medicare Hospice Benefit election requirements were not met.
Claims
- Question: A hospice is under a prepayment review with a commercial insurance payer. The payer is having system issues tracking medical records and processing claims. This is delaying the hospice’s ability to file claims to the primary payer. There are concerns that by the time the claims are processed, timely filing of Medicare Secondary Payer claims will be impacted. Can a hospice obtain a waiver of timely filing deadlines in these situations? If so, how would that be managed?
Answer: Timely filing exceptions are determined on a case-by-case basis. The provider would need to complete a Timely Filing Exception Request (PDF) and attach supporting evidence.
- Question: A hospice NOE cancelled with the remarks, “CANCEL PER MM/DD/YY EMAIL REQUEST FROM PRRS, CMS CPI INQUIRY.” The Provider Contact Center was not able to explain the code and why the claim cancelled. Several Hospice Coalition members researched this on the Palmetto GBA and the CMS websites and think that “PRRS” might be the Provider Relations Research Specialist.
Question 9a: Is that the right term for that PRRS acronym? Can you explain who PRRS is and why they would cancel a hospice claim?
Answer: The beneficiary submitted a dispute to Medicare regarding a questionable hospice election/services provided by a hospice. All claim submissions/hospice elections for the beneficiary may be cancelled until a review of the medical records is completed to allow the beneficiary to seek additional medical services.
A records request letter is mailed to the hospice. The hospice has a limited amount of business days to respond to the records request. These instances that follow this process have been rare. A Provider Relations Research Specialist (PRRS) for Palmetto GBA leads the actions in this process.
Question 9b: Do you have guidance on how a hospice can obtain information to reprocess the claim?
Answer: They must respond to the record request.
General
- Question: Some hospices continue to have problems locating a new Medicare Beneficiary Identifier (MBI) when a beneficiary has had a new MBI issued. They are trying to work with patients and families to get the new number. In the interim, the inability to process a Notice of Termination/Revocation (NOTR) or final claim is causing billing delays for other Medicare providers.
Question 10a: Does Palmetto GBA have guidance on what hospices can communicate to other provider types since they can’t file claims?
Answer: The Home Health and Hospice Billing When a New Medicare Beneficiary Identifier Is Assigned article provides direction on using eServices’ MBI Lookup tool to receive the current MBI. This should avoid billing delays.
Question 10b: Who maintains the Common Working File (CWF)? And does it take close to do updates to the CWF take up to 60 days?
Answer: The CWF Maintainer maintains CWF and timeframes for updates are based on their current workload.
- Question: Why is webchat with a live person no longer available? Will it be resumed? There is just a notice on the website stating it had to be closed: “Due to unforeseen circumstances, we have had to close our webchat feature effective immediately. We regret any inconvenience this may cause. However, our chatbot, Sage, remains available to assist you with checking claim status and our eServices Portal is available to assist you with a host of your Medicare needs.”
Answer: Palmetto GBA’s Web Chat resumed on June 2, 2025. Palmetto GBA also is happy to announce the introduction of our newest chat self-service tool, Chat Claim Status, for Part A and home health and hospice providers. You will be able to check Part A and home health, and hospice claim statuses through our chat application with the help of our automated digital assistant, Sage.
News to Share and Education Topics
- List of Unacceptable Principal Diagnosis Codes Under the Hospice Benefit
- Hospice Face-To-Face Encounter and Telehealth Technology