CMS Pub. 100-22, ch. 3, § 70

In calendar year 2007 and each subsequent year, if a home health agency does not submit required

quality data, their annual payment updates (APU) for the year are reduced by 2 percentage points.

Original Medicare considers the following data as meeting the reporting requirement:

• OASIS data submitted by HHAs for all episodes beginning on or after July 1 of the

previous year, and before July 1, of the current year, and

• Home Health Care Consumer Assessment of Health Providers and Systems (HHCAHPS)

monthly data collection and submission from April 1 of the prior year through March 31 of the

current year.

NOTE: If agencies have served 59 or fewer HHCAHPS-survey eligible patients in the year

immediately prior to the data collection year, and these agencies complete an HHCAHPS

Participation Exemption Request form for the APU year associated with the data collection year, then

they are exempt from HHCAHPS for the APU year. Annually, HHAs must count their patients in

the year prior to the data collection year to determine if they need to do HHCAHPS data

collection. The exemption form is on the HHCAHPS website, https://homehealthcahps.org. The

HHCAHPS Survey eligibility criteria are listed on the HHCAHPS website:

https://homehealthcahps.org/SurveyandProtocols/SurveyMaterials.aspx#catid1.

Illustration of HHCAHPS periods:

(A)

Annual

Payment

Update

Calendar

Year

(B)

Did the HHA

serve 60 or

more

HHCAHPS

eligible

patients in the

previous year?

(C)

If the HHA served 60 or

more survey eligible

patients in the previous

year, then the HHA must

collect HHCAHPS for the

year below.

(D)

If the HHA served 59 or less

survey eligible patients in the

previous year, then the HHA

must complete the Participation

Exemption Request form on the

HHCAHPS website in the “For

HHAs Only secure portal

Column C”. To receive an

exemption, the HHA must submit

a Participation Exemption

Request Form by the date noted

below.

2020 April 1, 2017 -

March 31, 2018 April 1, 2018 - March 31,

2019

March 31, 2019

2021 April 1, 2018 -

March 31, 2019 April 1, 2019 - March 31,

2020

March 31, 2020

Each fall, Medicare contractors with home health workloads will receive a technical direction

letter (TDL) which provides a list of HHAs that have not submitted the required OASIS and/or

HHCAHPS data during the established timeframes and which have submitted covered claims to

Medicare during these timeframes. The list(s) provided will have the facility name, CCN,

mailing information, reason for failure (OASIS or CAHPS or both) and will also provide the

MAC that should be sending out the letter.

The contractor shall notify the HHAs on the list that they have been identified as not being in

compliance with the requirement of submitting quality data and are scheduled to have Medicare reduce their

annual payment update (APU) by two percentage points.

Medicare contractors shall include the model language at the end of this section in their notification letter

to the HHA. The notification letter shall inform the HHA whether they were identified as not being in

compliance with the OASIS data requirement, the HHCAHPS data requirement, or both. Contractors

shall send notification letters no later than 5 business days from the receipt of the TDL.

Immediately after the notification letters are issued, Medicare contractors shall submit to the CMS contacts

noted in the TDL a list of agencies who received a letter. Medicare contractors shall notify home health

agencies who wish to dispute their payment reduction of the procedure to request a reconsideration. There

is a 30 day period from the date of the notification letter to submit a letter electronically requesting

reconsideration and documentation to support a finding of compliance.

Using the model language at the end of this section contractors shall inform HHAs about

documentation to support a finding of compliance.

For payments in calendar year 2011 and after, documentation of OASIS compliance may include any of

the following:

 evidence of OASIS transmissions during the reporting period (e.g., an OASIS Final Validation

Report from the CMS designated data submission system showing a timely submission date);

 for providers who received their initial survey in the period between January 1 and April 30 of the

reporting year, evidence that the HHA did not receive their CMS Certification Number (CCN) from

Medicare until after the close of the reporting year (e.g., a notification letter from the survey and

certification staff at the CMS RO dated after June 30);

 for providers who received their initial survey in the period between January 1 and April 30 of the

reporting year, evidence that they received their CCN too late in the reporting year for the provider

to receive their permanent OASIS transmitter ID from their State OASIS Automation Coordinator

and submit data (e.g., during the last week of June); or

 for providers who received their initial survey in the period between January 1 and April 30 of the

reporting year, evidence that the HHA received their CCN in the last weeks of the reporting year

(e.g., in June), took prompt action to request their permanent OASIS transmitter ID from their State

OASIS Automation Coordinator and were delayed by CMS or its agents.

For payments in calendar year 2012 and after, HHAs requesting reversal of the HHCAHPS

decision need to include the following:

 Evidence that the HHA continuously collected data for the 12 months, and submitted data

to the Home Health CAHPS Data Center during the required timeframe. The required 12

months are for April 1st through March 31st, or

• For HHAs that have served 59 or fewer HHCAHPS -survey eligible patients show

evidence of their census. If the HHAs have evidence of their completion of the

exemption form, then they should send a copy of their form.

The contractor shall inform HHAs that documentation of the following does not support a

finding of compliance:

 evidence or admission of error on the part of HHA staff, even if the involved staff members

are no longer employed by the HHA and/or a corrective action plan has been or will be put

in place after the end of the reporting year;

• evidence or assertion that failure to comply was the fault of a vendor or contractor that

was hired by the HHA to perform reporting functions (the HHA is responsible for the

actions of its contractors, vendors or other agents on the HHA’s behalf);

 evidence of delays establishing electronic data interchange connectivity between the HHA

and the Medicare claims processing contractor for the purpose of billing, since OASIS

transmission is not dependent on billing and the HHA should request their OASIS transmitter

ID from the State at the same time they request billing system access from the Medicare

claims processing contractor; and

 in cases where the ownership of the HHA changed during the reporting year but the CCN of

the HHA did not change, evidence that failure to comply was the fault of a previous owner.

Contractors should direct electronic submission of reconsideration requests and documentation to a

dedicated CMS e-mail address. If a provider’s documentation contains protected health

information (PHI) in error, documents containing PHI should not be forwarded. CMS will review

the documentation and provide a determination to the Medicare contractor as soon as possible, but

typically within a period of 6-7 weeks.

The following example illustrates the timeframes for the complete process using hypothetical

dates:

1) CMS issues the TDL providing the list of HHAs on Friday, September 17;

2) Contractors must issue notification letters to HHAs by the fifth business day after

receipt of the TDL, on September 24;

3) The timely reconsideration period ends 30 calendar days later, no later than October

24;

4) CMS provides determinations to contractors during the second week of December.

In its review of the HHA’s documentation, CMS will determine whether evidence to support a

finding of compliance has been provided by the HHA. The determination will be made based

solely on the documentation provided. CMS will not contact the HHA to request additional

information or to clarify incomplete or inconclusive information. If clear evidence to support a

finding of compliance is not present, the 2% reduction will be upheld. If clear evidence of

compliance is present, the reduction will be reversed.

If the CMS determination upholds the 2% reduction, CMS shall provide the Medicare contractor

with a statement of the findings that support the decision. The contractor shall notify the HHA in

writing and inform them of their right to further appeal the 2% reduction via the Provider

Reimbursement Review Board (PRRB) appeals process. Medicare contractors shall include the

model language at the end of this section in their dispute determination letter to the HHA.

Contractors shall insert the CMS-provided statement of findings in the blank provided in the

model language. Contractors shall send this second letter only to HHAs that requested a

reconsideration.

If the HHA does not dispute their reduction, the Medicare contractor shall update their provider

file for the HHA. The contractor shall set an indicator in the provider file that triggers Medicare

systems to calculate the 2% reduction on all claims for the upcoming calendar year. If the CMS

determination upholds the 2% reduction, the contractor shall update their provider file in this

fashion also.

If the CMS determination reverses the 2% reduction, the contractor shall not update their

provider file for the HHA and shall notify the HHA that they will receive their full HH PPS

annual payment update (APU) for the upcoming year.

Model language for initial notification letters:

“This letter is to officially inform you that CMS has determined your home health agency (HHA) is

subject to a reduction in the annual payment update for not meeting the Deficit Reduction Act (DRA) of

2005 requirement for HHAs to submit quality data. Therefore, Medicare payments to your agency will

be reduced for [insert upcoming year], unless you can provide evidence that this determination is in

error.

Currently, the quality data reporting requirement consists of timely submission of Outcomes

and Assessment Information Set (OASIS) data as required by your conditions of

participation (CoPs), and timely submission of Home Health Care Consumer Assessment of

Health Providers and Systems (HHCAHPS) data.

In order to meet the CoPs, OASIS data is required to be transmitted within 30 days of the

assessment date. OASIS data submitted within 30 days of the assessment date is considered to

have met the requirement of submitting the required quality data. The reporting year for [insert

upcoming year] was the period between July 1, [insert previous year] and June 30, [insert

current

year]. Under the CoPs, assessments in June [insert current year] would meet the requirement if

submitted by July 31, [insert current year]. New HHAs, defined as agencies with participation

dates in the Medicare program on or after May 1, [insert current year], are excluded from this

requirement.

[For letters in calendar year 2012 only:]

In order to meet the HHCAHPS requirement, HHAs needed to participate in an HHCAHPS dry

run in third quarter 2010, and continue monthly data collection and submission of data to the

Home Health CAHPS Data Center beginning in October 2010, through March 2011. If

agencies had less than 60 patients between April, 1, 2009, and March 31, 2010, then they were

exempt from HHCAHPS participation for CY 2012. These HHAs were to complete an

HHCAHPS Participation Exemption Request form for CY 2012 on the HHCAHPS Website,

https://homehealthcahps.org.

[For letters in calendar years 2013 and after:]

In order to meet the HHCAHPS requirement, HHAs must collect monthly HHCAHPS data and

submit data to the Home Health CAHPS Data Center from April 1, [insert the prior year] through

March 31,[insert the current year]. If agencies had 59 or fewer HHCAHPS-survey eligible

patients between April 1, [insert the year 2 years prior] and March 31, [insert the prior year], then

they are exempt from HHCAHPS participation for [insert current year]. These HHAs were to

complete an HHCAHPS Participation Exemption Request form on the HHCAHPS Website,

https://homehealthcahps.org.

CMS review of OASIS and HHCAHPS submissions for this period found that your agency is not

excluded or exempt from the reporting requirements and [insert whether the HHA was non-compliant with OASIS, HHCAHPS or both]. CMS’s review of paid claims has shown that you

have received Medicare payment for claims with dates of service within the reporting year.

Consequently, for episodes that end on or after January 1, [insert upcoming year] and prior to

January 1, [insert following year], annual payment updates to your agency will be reduced by 2%.

The national 60-day episode payment amount and the national standardized per-visit amounts used

to calculate low utilization payment adjustments (LUPAs) and outlier payments for providers that

did not submit quality data, are listed in separately labeled tables in the recent HH PPS payment

update final regulation for [insert upcoming year].

If you believe you have been in compliance with the quality data reporting requirement and have

been identified for this payment reduction in error, you must submit a letter requesting

reconsideration and provide documentation demonstrating your compliance.

Documentation to support a finding of compliance with OASIS reporting may include any of the

following:

 evidence of OASIS transmissions during the reporting period (e.g., an OASIS Final

Validation Report from the national system showing a timely submission date);

 if your HHA received your initial survey in the period between January 1 and April 30 of

the reporting year, evidence that your HHA did not receive your CMS Certification Number

(CCN) from Medicare until after the close of the reporting year (e.g., a

notification letter from the survey and certification staff at the CMS RO dated after June

30);

 if your HHA received your initial survey in the period between January 1 and April 30 of

the reporting year, evidence that your HHA received your CCN too late in the reporting

year to request and receive your permanent OASIS transmitter ID and submit data (e.g.,

during the last week of June); or

 if your HHA received your initial survey in the period between January 1 and April 30 of

the reporting year, evidence that your HHA received your CCN in the last weeks of the

reporting year (e.g., in June), took prompt action to request your permanent OASIS

transmitter ID and were delayed by CMS or its agents.

Documentation to support a finding of compliance with HHCAHPS reporting may include any of

the following:

 Evidence that the HHA continuously collected data and submitted data to the Home

Health CAHPS Data Center during the required timeframe. [For letters in calendar year

2012 only:] The required period of data collection includes the dry run data in the third

quarter 2010, the fourth quarter 2010 (all the months of October, November and

December 2010), and the first quarter 2011 (all the months of January, February, and

March 2011). [For letters in calendar year 2013 and after:] The required period of data

collection includes all months from April 1, [insert the prior year] through March 31,

[insert the current year]; or

 For HHAs that have served 59 or fewer HHCAHPS -survey eligible patients in the year

from April 1, [insert the year 2 years prior] and March 31, [insert the prior year], evidence

that the HHA filed the Participation Exemption Request Form, on the form that is on

www.homehealthcahps.org, by the deadline date specified in the HH PPS payment

update final regulation for [insert current year].

Note that documentation of the following does NOT support a finding of compliance:

 evidence or admission of error on the part of your staff, even if the involved staff members

are no longer employed by your HHA and/or a corrective action plan has been or will be

put in place after the end of the reporting year;

 evidence or assertion that failure to comply was the fault of a vendor or contractor that

was hired by your HHA to perform reporting functions;

 evidence of delays establishing electronic data interchange connectivity between your

HHA and [insert Medicare contractor name] for the purpose of billing, since OASIS

transmission is not dependent on billing and the HHA should request their OASIS

transmitter ID from the State at the same time they request billing system access

from [insert Medicare contractor name]; or

 in cases where the ownership of the HHA changed during the reporting year but the CCN

of the HHA did not change, evidence that failure to comply was the fault of a previous

owner.

Your letter and documentation should be submitted via e-mail to CMS for reconsideration,

using the following e-mail address: HHAPUreconsiderations@cms.hhs.gov .

Requests and supporting documentation must be received electronically no later than 30 days

from the date of this notification.

When preparing your request, be careful to ensure the following:

 Documents provided are relevant to the reason for your payment reduction (i.e. do not

send OASIS documentation in response to a HHCAHPS related reduction)

 No protected health information (PHI) is included in the documents

 All documents pertain to the same, current reporting year

 Each request provides documents regarding a single HHA (do not combine requests or

attach a list of HHA provider numbers to a request)

 If requesting a HHCAHPS reconsideration regarding a participation exception, provider

specific information detailing why your HHA had no eligible patients.

An HHA must submit a request for reconsideration and receive a decision on that request before

they can file an appeal with the Provider Reimbursement Review Board (PRRB).”

Model language for dispute determination letters:

“This letter is in response to your request for reconsideration of the scheduled 2% Annual

Payment Update reduction in payments to your agency, due to your agency being identified

as [insert whether the HHA was non-compliant with OASIS, HHCAHPS or both].

CMS has reviewed the documentation you provided and determined that your agency is subject to

the 2% reduction in the Annual Payment Update for CY [insert upcoming year], due to your

agency’s noncompliance with submitting quality data during the required timeframes. Specifically,

CMS officials found [insert CMS-provided statement of findings]. If your agency wishes to

further appeal this determination, the appeals process set forth in 42 CFR Part 405, Subpart R (a

Provider Reimbursement Review Board (PRRB) appeal) applies.

Exhibit 1 – Incentive Payment Results Report

(Rev. 11, Issued: 03-26-13, Effective: 06-25-12, Implementation: 06-25-12)

Contractors are to insert the change request (CR) number for the recurring update notification

associated with the PQRS or eRx payment in the title of the Incentive Payment Results Report

displayed in Exhibit 1.

Exhibit 1 – Incentive Payment Results Report

(Rev. 11, Issued: 03-26-13, Effective: 06-25-12, Implementation: 06-25-12)

Contractors shall report the following to CMS for each workload:

Glossary of terms:

Workload – each contractor number for which the MAC is responsible (Example: 01503, 01504, 01505)

Payment/Paid – check has been invoiced and mailed or check has been sent via EFT

1. Have you verified that the incentive payments have made it through every aspect of processing to payment?

Yes _____ No_____

2. Do you have documentation available confirming that all payments have been paid to eligible professionals?

Yes_____ No_____

3. Annotate how many incentive checks you were scheduled to pay per the payment file received from the CMS mainframe.

# of checks scheduled to be paid = _____

Note: Use one line to report for each workload. The totals in this chart should equal the number of checks annotated above that the

contractor was scheduled to pay.

MAC/Carrier Contractor

Number

States Number

of Checks

Paid

Total Dollar

Amount for

Checks Paid

Number of Checks Not

Paid

Provide details in chart 4

Total Dollar Amount

for Checks NOT paid

Provide details in chart 4

Example: 00000 AK 225 $17,234.50 10 $2,359.00

Totals

4. Annotate the details for incentive checks “Not Successfully” paid due to the appropriate reason below.

# of checks “Not Successfully” paid = _____:

Note: This chart should only show details for payment issues that remain unresolved as of the date of this report. If you encountered a

payment issue and it has been resolved, do not report it in this chart.

MAC/Carrier Contractor

Number

States # of

HIGLAS

Rejections

Total

Dollar

Amount

for

HIGLAS

rejections

# of

Invalid

TIN(s)

Provide

details in

Chart 5

Total

Dollar

Amount

for

Invalid

TINs

# of Do

Not

Forwards

(DNFs)

*No follow up

is required for

DNFs.

Total

Dollar

Amount

for DNFs

# of

Other

Provide

details in

chart 6

Total

Dollar

Amount

for

Checks

not paid

for

“Other”

reasons

Grand Total

of ALL

checks “Not

Successfully”

paid

Example:

Totals

5. Provide details of unresolved payment issues for payments associated with invalid TINs:

MAC/Carrier Contractor Number State Invalid TIN number(s) Payment Amount

6. Provide details on unresolved payment issues for payments in “Other” column

MAC/Carrier Contractor Number Details for Payment issue(s) annotated in table 4

Add additional rows to report as necessary.

Exhibit 2 – PQRS and eRx Incentive Payment File Record Layout

(Rev. 11, Issued: 03-26-13, Effective: 06-25-12, Implementation: 06-25-12)

The PQRS and eRx incentive payments are not combined into one file. Each incentive has its

own separate file.

Exhibit 2

(Rev. 11, Issued: 03-26-13, Effective: 06-25-12, Implementation: 06-25-12)

PQRS and eRx INCENTIVE PAYMENT FILE

RECORD LAYOUT

FIELD NAME

0BSTART/END

POSITION PIC COMMENT

HEADER RECORD

Header Indicator 1-4 X(4) Value “HEAD”

Header Record Number 5-5 X(1) Value 1 to 9

Filler 6-6 X(1) Value spaces

Incentive Type Year

Indicator

7-10 X(4)

--Incentive Type 7-8 X(2) Value PQ denotes PQRS Incentive; Value

RX denotes eRx Incentive. NOTE: Each

incentive will have its own separate file;

they are not combined into one file.

--Incentive Reporting Year 9-10 X(2) Value denotes reporting year for Incentive

Filler 11-125 X(115) Value spaces

DATA RECORD

Carrier/MAC Number 1-5 X(5) Left justified.

FILLER 6-24 X(19) Value spaces (in the future, this field may

contain the NPI).

Incentive Recipient Tax ID 25-34 X(10) Left justified, one blank field.

FILLER 35-39 X(5) Value spaces

Incentive Amount 40-49 9(8)v99

FILLER 50 X(1) Value spaces

Report Start Date 51-58 X(8) CCYYMMDD (beginning time period for

reporting of claims for PQRS or eRx; i.e.

January 1, 2009).

FILLER 59 X(1) Value spaces

Report End Date 60-67 X(8) CCYYMMDD (ending time period for

reporting of claims for PQRS or eRx; i.e.

December 31, 2009).

FILLER 68-125 X(58) Value spaces