CMS Pub. 100-04, ch. 3, § 180

Contractors Without RNHCI Specialty Workloads

(Rev. 11963, Issued:04-20-23, Effective: 10-01-23, Implementation, 10-02-23)

While elections and claims for RNHCI services are processed by the Medicare contractor with

RNHCI specialty workload, all Medicare contractors (below ‘non-specialty contractors’)

must understand the nature and purpose of the RNHCI election and the definitions of

excepted and non-excepted care defined in Pub. 100-02, Medicare Benefit Policy Manual,

Chapter 1, Section 130. Non-specialty contractors may find it advisable to have an

identified specialist (or specialists) familiar with excepted and nonexcepted care used in the

review of beneficiaries with RNHCI elections, since this process is so unlike other Medicare

claims processes.

Beneficiaries may revoke their RNHCI election by submitting a written revocation request to

Medicare, but this is rare. Far more commonly, beneficiaries revoke the election simply by

receiving nonexcepted medical services and requesting Medicare payment for those services.

Any non-specialty contractor may receive a claim for services for a beneficiary with an RNHCI

election currently in place. This section provides instructions to non-specialty contractors for

the handling of such claims.

Upon receipt of a claim for payment, non-specialty contractors will not be aware that the

beneficiary has an RNHCI election in place and will process the claim normally to the point of

transmitting the claim to CWF. The CWF searches beneficiary records for all claims to

determine whether an RNHCI election is found. If an election is found, CWF takes one of two

actions on a claim for non-RNHCI services:

• If the claim is for DME, or prosthetic/orthotic devices, CWF will accept the

DMEPOS claim and revoke the RNHCI election. All DMEPOS claims are treated

as nonexcepted medical care.

• If the claim is for COVID-19 vaccine services and no other covered services, CWF will

accept the claim and leave the RNCHI election in place. All COVID-19 vaccines and

their administrations are treated as excepted medical care.

• If the claim is for any other Medicare covered services, CWF initially rejects it to

the non-specialty contractor. The non-specialty contractor must determine whether the

care was excepted or nonexcepted. The claim must never be automatically denied.

The RNHCI election revocation does not interfere with the beneficiary’s ability to seek

other Medicare services within the limits of their Medicare coverage.

The process for non-specialty contractors to follow in responding to this CWF edit is unique

among Medicare claims processes. A determination must be made whether the beneficiary’s

RNHCI election should be revoked. Therefore, unlike other CWF rejects which are processed

in an automated fashion, claims rejected by CWF due to the presence of an RNHCI election

must be suspended and developed to determine if the beneficiary received excepted care.

At differing points in time, this review consisted of a request for medical records or a series of

telephone contacts but these methods were found too workload intensive. In response to a

CWF reject due to the presence of an RNHCI election, non-specialty contractors must issue a

simple development letter asking the provider of services to respond in a yes or no fashion to

three questions:

• Whether the beneficiary paid for the services out of pocket in lieu of requesting

payment from Medicare;

• Whether the beneficiary was unable to make his/her beliefs and wishes known before

receiving the services that have been billed; and

• Whether, for a vaccination service, the vaccination performed was required by a

government jurisdiction.

Each non-specialty contractor may develop the wording and format of this letter based on their

experience effectively communicating with their community of providers.

The purpose for this development letter is to determine whether the care received is excepted

(leaving the election intact) or whether it is nonexcepted (causing a revocation of the RNHCI

election). Provider responses of ‘No’ to all questions in the letter will determine that the

services are found to be non-excepted care. Provider responses of ‘Yes’ to the questions

regarding inability to make beliefs known or regarding required vaccinations will determine

that the services are found to be excepted care. Unless reasons to deny these claims are found

during the course of claims processing, these claim will normally be paid. A provider response

of ‘Yes’ to the question regarding the beneficiary’s paying out of pocket will determine that the

services are found to be excepted care, but the claim for payment for medical care must be

denied. The claim must be denied because the beneficiary has not made a request for Medicare

payment. The beneficiary has accepted liability for these services in order to protect their

RNHCI election.

Once the non-specialty contractor makes this determination of whether the care is excepted or

nonexcepted, the claim record is annotated accordingly (see section 180.1 below) and returned

to CWF. The claim will be approved for payment and if the care was found to be nonexcepted

CWF will cause the beneficiary’s RNHCI election to be revoked.

In the event that the provider does not reply timely to the development letter, non-specialty

contractors must make an excepted/nonexcepted determination based on the evidence

presented by the claim itself. Non-specialty contractors shall apply the same timeliness

standard to these responses as to all other documentation requests. If the claim contains

durable medical equipment or prosthetic/orthotic devices, the non-specialty contractor

may make a determination of nonexcepted care on that basis alone. All such claims are

treated as nonexcepted care. For all other claims, non-specialty contractor staff with a

clinical background must make their best determination based on the diagnoses and

procedures reported on the claim whether the services were excepted or nonexcepted care.

In cases where the determination cannot be made with certainty but there is some reason

to suspect services were nonexcepted care, the non-specialty contractor shall make a

determination of nonexcepted care and annotate the claim record accordingly.

Determinations must be made within the earlier of 30 days of receipt of the provider’s

response or 30 days of the end of the timely response period.

The importance of the development of these claims lies in its effect on the beneficiary. If

the claim for medical care is denied improperly based on the presence of the RNHCI

election, the beneficiary will incur liability in error and may experience financial hardship.

Similarly, it is important that the review result in accurate determinations of nonexcepted

care since repeated revocations of this benefit can have an impact on the beneficiary’s right

to access the RNHCI benefit in the future.