CMS Pub. 100-04, ch. 10, § 30.1

Under the HH PPS and home health consolidated billing one HHA is considered the

“primary” home health agency in billing situations. This primary agency is the only

agency that may bill Medicare for home care for a given homebound beneficiary at a

specific time. When a homebound beneficiary seeks care from an HHA or from an

institutional therapy provider subject to home health consolidated billing, the provider

needs to determine if the beneficiary is already being served by an HHA - an agency that

then would be considered primary.

Providers may send an inquiry to determine the beneficiary’s entitlement and eligibility

status into the Common Working File or CWF, through their A/B MAC (A) or (HHH).

They must send the ASC X12 270 Health Care Eligibility Inquiry transaction set and will

receive the ASC X12 271 Health Care Eligibility Response transaction set in response, in

order to comply with the requirements of the Health Insurance Portability and

Accountability Act.

A/B MACs (A) or (HHH) processing institutional claims will create an ELGH record

from the 270 to request this data from CWF and will receive the ELGA record from CWF

in response. The A/B MAC (A) or (HHH) will create the 271 response or DDE screen

from the ELGA transaction record.

The response shows whether or not the beneficiary is currently in a home health

admission period. If the beneficiary is not already under care at another HHA, he/she can

be admitted to the inquiring HHA, and that agency will become primary. The beneficiary

can also be admitted even if an admission period is already open at another HHA if the

beneficiary has chosen to transfer.

See chapter 31 for a description of the data elements and related requirements.