CMS Pub. 100-04, ch. 10, § 60

Home health agencies may seek denials for entire claims from Medicare in cases where a

provider knows all services will not be covered by Medicare. Such denials are usually

sought because of the requirements of other payers for providers to obtain Medicare

denial notices before they will consider providing additional payment. Such claims are

often referred to as no-payment bills or billings for denial notice.

A. Submission and Processing

In order to submit a no-payment bill to Medicare under HH PPS, providers must use TOB

0320, and condition code 21. Claims with condition code 21 and any other TOB will be

returned to the provider for correction. A Notice of Admission (TOB 032A) is not

required before the submission of a claim with TOB 0320 and condition code 21.

The statement dates on the claim should conform to the billing period they plan to submit

to the other payer, insuring that no future date is reported. Providers must also submit the

charge for each line item on the claim as a non-covered charge.

In order for these claims to process through the subsequent HH PPS edits in the system,

providers are instructed to submit a 0023 revenue line on the claim. If no OASIS

assessment was done or if the HHA chooses not to perform payment grouping before

submitting the claim, report any valid HIPPS code.

The claim must meet other minimum Medicare requirements. If an OASIS assessment

was done and the HHA chooses to perform payment grouping for their internal

accounting purposes, the HHA may report the resulting HIPPS code.

B. Simultaneous Covered and Non-Covered Services

In some cases, providers may need to obtain a Medicare denial notice for non-covered

services delivered in the same period as covered services that are part of an HH PPS

period of care. In such cases, the provider should submit a non-payment bill according to

the instructions above for the non-covered services alone, AND submit the appropriate

NOA and claim for the HH PPS period of care. The period billed under the HH PPS

claim and the non-payment bill should be the same. Medicare standard systems and the

CWF will allow such duplicate claims to process when all services on one claim are non-covered.

C. Custodial Care under HH PPS, or Termination of the Benefit during a Period

In certain cases, Medicare allows the use of no payment claims in association with an

ABN involving custodial care and termination of a benefit during a period of care. This

does not apply to cases in which a determination is being requested as to the beneficiary’s

homebound status at the beginning of a period of care; there an ABN must be used

assuming a triggering event occurs (i.e., the initiation of completely noncovered care).

However, in cases where the HH plan of care prescribes only custodial care, or if the

benefit has terminated during a previous period, and the physician, beneficiary, and

provider are all in agreement the benefit has terminated or does not apply, home health

agencies (HHAs) can use:

1. The ABN for notification of the beneficiary, and,

2. A condition code 21 no-payment claim to bill all subsequent services.