CMS Pub. 100-04, ch. 10, § 40.1

HHAs must send the NOA to the A/B MAC (HHH) by mail, electronic data

interchange (EDI), or direct data entry (DDE). EDI submissions require additional data

not required by the NOA itself, to satisfy transaction standards. This data is described in a

companion guide available on the CMS website. HHAs may voluntarily agree to adopt

the companion guide and use it to submit EDI NOAs at any time.

The following data elements are required to submit an NOA under HH PPS.

Provider Name, Address, and Telephone Number

Required - The minimum entry is the agency’s name, city, State, and ZIP Code. The post

office box number or street name and number may be included. The State may be

abbreviated using standard post office abbreviations. Five or nine-digit ZIP Codes are

acceptable. This information is used in connection with the CMS Certification Number

to verify provider identity.

Type of Bill

Required -

032x - Home Health Services under a Plan of Treatment

4th Digit Definition

A Admission/Election Notice

D Cancellation of Admission/Election Notice

Statement Covers Period (From-Through)

Required – The HHA reports the date of the first visit provided in the admission as the

From date. The Through date on the NOA must always match the From date.

Patient Name/Identifier

Required - Patient’s last name, first name, and middle initial.

Patient Address

Required - Patient’s full mailing address, including street number and name, post office

box number or RFD, City, State, and ZIP Code.

Patient Birth Date

Required - Month, day, and year of birth of patient.

Left blank if the full correct date is not known.

Patient Sex

Required - “M” for male or “F” for female must be present. This item is used in

conjunction with diagnoses and surgical procedures to identify inconsistencies.

Admission/Start of Care Date

Required - The Admission date on the NOA must always match the From date.

Condition Codes

Conditional. - If the NOA is for a patient transferred from another HHA, the HHA enters

condition code 47.

Note: No line item service information is required by the Medicare program to complete

a Notice of Admission via DDE. However, certain line information is required to meet

the requirements of the 837I claim format. See the NOA Companion Guide for details

on meeting these requirements.

Release of Information Certification Indicator

Required - A “Y” code indicates the provider has on file a signed statement permitting

the provider to release data to other organizations in order to adjudicate the claim. An

“R” code indicates the release is limited or restricted. An “N” code indicates no release

on file.

National Provider Identifier – Billing Provider

Required - The HHA enters their provider identifier.

Insured’s Name

Required - On the same lettered line (A, B, or C) that corresponds to the line on which

Medicare payer information is shown, record the patient’s name as shown on the patient’s

HI card or other Medicare notice.

Insured’s Unique Identifier

Required – The HHA enters the beneficiary’s Medicare Beneficiary Identifier (MBI).

Confirm the MBI is active via an eligibility inquiry to avoid delays in the timely receipt

or processing of the NOA.

Principal Diagnosis Code

Required to meet the requirements of the 837I claim format. See the NOA Companion

Guide

Attending Provider Name and Identifiers

Required - The HHA enters the name and provider identifier of the attending physician

that has established the plan of care with verbal orders.