CMS Pub. 100-04, ch. 11, § 20.1.2

NOTR is used when the hospice beneficiary is discharged alive from the hospice or

revokes the election of hospice services. An NOTR should not be used when a patient is

transferred.

If a hospice beneficiary is discharged alive or if a hospice beneficiary revokes the

election of hospice care, the hospice shall file a timely-filed Notice of Election

Termination / Revocation (NOTR), unless it has already filed a final claim. A timely-filed

NOTR is a NOTR that is submitted to the A/B MAC (HHH) and accepted by the A/B

MAC (HHH) within 5 calendar days after the effective date of discharge or revocation.

While a timely-filed NOTR is one that is submitted to and accepted by the A/B MAC

(HHH) within 5 calendar days after the hospice election, posting to the CWF may not

occur within that same timeframe. The date of posting to the CWF is not a reflection of

whether the NOTR is considered timely-filed.

In order for the NOTR to be accepted into the system, an election period must be

established. If the notice of election, which creates the hospice election period is not

submitted and posted before the NOTR, the NOTR will be rejected.

Type of Bill

Enter the appropriate 3-digit numeric type of bill code, according to the following code

structure:

81B - Hospice (Non-hospital Based) NOTR

82B - Hospice (Hospital Based) NOTR

Statement Covers Period (From-Through)

• The hospice submits the From date on an NOTR differently in the following

scenarios: When there is no change in the provider number during the election,

the hospice must submit the start date of the election period as the From date on

the NOTR.

• If the revocation follows a transfer, the From date on the NOTR must match the

START DATE2 on the benefit period that initiated the transfer.

• If the revocation follows a change of ownership, the From date on the NOTR

must match the OWNER CHANGE start date on the benefit periods. This process

is to ensure that only the provider currently providing services to the beneficiary

can submit the NOTR.

In all cases, the Admission Date on the NOTR must match the From date.

Patient’s Name

The patient’s name is shown with the surname first, first name, and middle initial, if any.

Patient’s Address

The patient’s full mailing address including street name and number, post office box

number or RFD, city, State, and ZIP code.

Patient’s Birth Date

Show the month, day, and year of birth numerically as MM-DD-YYYY.

Patient’s Sex

Show an “M” for male or an “F” for female. This item is used in conjunction with

diagnoses and surgical procedures to identify inconsistencies.

Admission Date

The hospice enters the admission date, which must be the start date of the benefit period

in all cases except when a transfer occurs.

On a NOTR, the hospice enters the start date of the hospice benefit period in which the

discharge or revocation is effective, not the initial hospice admission date.

Show the month, day, and year numerically as MM-DD-YY.

Facility Zip Code

Enter the hospice's ZIP code (9-digit). The ZIP code entered must match the ZIP code in

the Master Address field of the provider's address file.

Condition Codes

Condition codes are not required on an original NOTR. If the hospice is correcting a

revocation date using occurrence code 56, the hospice reports condition code D0. If the

two codes are not reported together, the NOTR will be returned to the hospice.

Occurrence Codes and Dates

Hospices may submit an NOTR that corrects a revocation date previously submitted in

error. In this case, the hospice reports the correct revocation date in the Through Date

field and reports the original, incorrect revocation date using occurrence code 56.

Medicare systems use the original, incorrect date to find the election record to be

corrected, then replaces that revocation date with the corrected information.

If a revocation date was submitted entirely in error (for instance, the beneficiary actually

transferred to another hospice, rather than revoking their hospice benefit), the hospice can

remove the revocation date via Direct Data Entry by submitting TOB 8xB with zeroes in

the Through date. The hospice reports the original, incorrect revocation date on the

NOTR using occurrence code 56 and indicate the NOTR is a correction by adding

condition code D0.

Release of Information

Valid values are:

I- Informed consent to release medical information for condition or diagnoses

regulated by Federal Statutes

Y - Yes, provider has a signed statement permitting release of information.

Provider Number

The hospice enters their NPI. Medicare systems ensure that the provider number

submitted on the NOTR is the currently active billing provider (e.g. the provider number

matches that on the hospice election period or the most recent transfer date or change of

ownership date on any benefit period). If any other provider number is submitted, the

NOTR is returned.

Insured’s Name

Send all NOEs with Medicare as the primary payer. Enter the beneficiary’s name on line

A. Show the name exactly as it appears on the beneficiary’s HI card.

Insured’s Unique Identifier

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

payer information is shown enter the patient’s unique identifier by the health plan for the

insured. For example, if Medicare is the primary payer, enter the MBI. To ensure

accuracy and prevent a delay in the timely receipt or posting the hospice notice of

election, hospices should validate this information using the Health Insurance Portability

and Accountability Act (HIPAA) Eligibility Transaction System (HETS). Only in the

event that the HETS data is not available should the hospice show the number as it

appears on the patient’s HI Card, Social Security Award Certificate, Utilization Notice,

EOMB, Temporary Eligibility Notice, etc., or as reported by the SSO.

Principal Diagnosis Code

CMS accepts only HIPAA approved ICD-9-CM or ICD-10-CM/ICD-10-PCS codes,

depending on the date of service. The official ICD-9-CM codes, which were updated

annually through October 1, 2013, are posted at

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

The official annual updates to ICD-10-CM and ICD-10-PCS codes are posted at

http://www.cms.gov/Medicare/Coding/ICD10/index.html

Use full diagnosis codes including all applicable digits, up to five digits for ICD-9-CM

and up to seven digits for ICD-10-CM.

Attending Physician I.D.

The hospice enters the name and provider identifier of the attending physician designated

by the patient at the time of election as having the most significant role in the

determination and delivery of the patient’s medical care. The patient’s designated attending physician

could be an independent physician, hospice physician, a nurse practitioner, or physician assistant. If

there is no attending physician listed, then the hospice shall report the hospice certifying/recertifying

physician.

Other Physician I.D.

The hospice enters the name and provider identifier of the hospice physician responsible for

certifying/recertifying that the patient is terminally ill, with a life expectancy of 6 months or less if the

disease runs its normal course. For electronic claims, this information is reported in Loop ID 2310F –

Referring Provider Name.

NOTE: Both the attending physician and other physician fields should be completed unless the

patient’s designated attending physician is the same as the physician certifying/recertifying the

terminal illness. When the attending physician is also the physician certifying/recertifying the

terminal illness, only the attending physician field is required to be populated, the other physician

field would not need to be populated.

Provider Representative Signature and Date

A hospice representative must make sure the required physician’s certification, and a signed hospice

election statement are in the records before signing the Form CMS-1450. A stamped signature is

acceptable.