Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 205 Date: August 28, 2018

Transcription

1 anual ystem Pub emonstrations epartment of ealth & uman ervices () enters for edicare & edicaid ervices () Transmittal 205 ate: ugust 28, 2018 hange Request Transmittal 203, dated ugust 10, 2018, is being rescinded and replaced by Transmittal 205, dated, ugust 28, 2018, to replace the word "three" with "four" in the ummary of hanges. ll other information remains the same. UBJT: Next Generation ccountable are Organization (O) odel 2019 Benefit nhancement. URY O NG: This hange Request (R) provides instruction to edicare payment contractors to implement one new benefit enhancements for program year four of the Next Generation O program. laims for are anagement ome isit aiver shall be processed for reimbursement and paid when they meet the appropriate payment requirements as outlined in this R. This R also includes instructions to modify the current ll nclusive Population Based Payment (PBP) and Population-Based Payment (PBP) enhancements in the Next Generation O program, as well as modifies which ealthcare ommon Procedure oding ystem (P) codes providers may use to bill for the current Post-ischarge ome isit waiver enhancement. T T: January 1, 2019 *Unless otherwise specified, the effective date is the date of service. PLNTTON T: January 7, 2019 isclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NG N NUL NTRUTON: (N/ if manual is not updated) R=R, N=N, =LT-Only One Per Row. R/N/ N/ PTR / TON / UBTON / TTL N/. UNNG: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of ork. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.. TTNT: emonstrations

2 ttachment - emonstrations Pub Transmittal: 205 ate: ugust 28, 2018 hange Request: Transmittal 203, dated ugust 10, 2018, is being rescinded and replaced by Transmittal 205, dated, ugust 28, 2018, to replace the word "three" with "four" in the ummary of hanges. ll other information remains the same. UBJT: Next Generation ccountable are Organization (O) odel 2019 Benefit nhancement T T: January 1, 2019 *Unless otherwise specified, the effective date is the date of service. PLNTTON T: January 7, GNRL NORTON. Background: The aim of the Next Generation O odel is to improve the quality of care, population health outcomes, and patient experience for the beneficiaries who choose traditional edicare ee-for-ervice (). The benefit provides greater alignment of financial incentives and greater access to tools that may aid beneficiaries and providers in achieving better health at lower costs. n order to emphasize high-value services and support the ability of Os to manage the care of beneficiaries, is issuing the authority under section 1115 of the ocial ecurity ct (section 3021 of the ffordable are ct) to conditionally waive certain edicare payment requirements as part of the Next Generation O odel. n O may choose not to implement all or any of these benefit enhancements. pplicants will be asked questions specific to their proposed implementation of these benefit enhancements, but acceptance into the Next Generation O odel is not contingent upon an O implementing any particular benefit enhancement. Participants in the Next Generation O odel are required to provide implementation information to, which, upon approval, will enable the O s use of the optional benefit enhancements. ach optional benefit enhancement will have such an implementation plan requiring, for example: (1) descriptions of the O s planned strategic use of the benefit enhancement; (2) self-monitoring plans to demonstrate meaningful efforts to prevent unintended consequences; and (3) documented authorization by the governing body to participate in the benefit enhancement. RT nternational is the specialty contractor creating the Next Generation O provider alignment files. B. Policy: ection 1115 of the ocial ecurity ct (the ct) (added by section 3021 of the ffordable are ct) (42 U a) authorizes the enter for edicare & edicaid ervices () to test innovative health care payment and service delivery models that have the potential to lower edicare, edicaid, and the hild ealth nsurance Program (P) spending while maintaining or improving the quality of beneficiaries care. The Next Generation O odel will implement design elements with implications for the system for the fourth performance year that includes a benefit enhancement to give Os the tools to direct care and engage beneficiaries in their own care. This R also makes slight modifications to the operations of current benefit enhancements offered by the odel. New Benefit nhancement for 2019

3 are anagement ome isits Building upon the Next Generation Os experience in offering the Post-ischarge ome isits benefit enhancement, the model will offer a new are anagement ome isits benefit enhancement to equip the Next Generation Os with a new tool to provide home visits proactively and in advance of a potential hospitalization. Next Generation participants and preferred providers who have initiated a care treatment plan for aligned beneficiaries will be eligible to receive up to two are anagement ome isits within 90 days of seeing that Next Generation participant or preferred provider. This is not a home health benefit and beneficiaries eligible to receive home health services will not be eligible for this benefit enhancement. The items and services provided as part of these care management home visits are intended to supplement, rather than substitute for, visits to a primary care provider or specialist in a traditional health care setting. s such, these home visits are not intended to be performed on an ongoing basis, nor to serve as a substitute for the edicare home health benefit, nor as the primary mechanism to meet beneficiaries care needs. e will extend the conditional edicare payment rule waiver issued under the Post-ischarge ome isits benefit enhancement to establish the are anagement ome isits benefit enhancement. pecifically, the scope of covered items and services under this benefit enhancement include those services and supplies that would be covered under edicare Part B, and are furnished incident to the professional services of a physician or other practitioner. ith the exception that will waive the direct supervision requirement such that the services and supplies may be furnished by auxiliary personnel under the billing physician s or other billing practitioner s general supervision. This new are anagement ome isits benefit enhancement will provide Next Generation participants and preferred providers greater flexibility to furnish these services within a beneficiary s home or place of residence.. BUN RQURNT TBL "hall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility hared- ystem aintainers ffective January 1, 2019, contractors shall prepare their systems to process NG O care management home visit claims with dates of service January 1, 2019 and later. B T shall include the following data elements/fields on the provider alignment file: 1. Record Type (ndicator values identified by a single character) 1. are anagement ome isits = alue 7 T The O-Operational ystem (O) shall send the ulti-arrier ystem () the Next Generation O provider alignment file that's been updated to include indicator 7 for the are anagement ome isits benefit enhancement.

4 hared- ystem aintainers B ontractors shall note that a provider can have multiple enhancements, including are anagement ome isits The contractors shall process NG O claims as are anagement ome isits claims when the benefit enhancement indicator "7" is identified on the provider alignment file ontractors shall add the ealthcare ommon Procedure oding ystem (P) G G0080 to the edicare ummary Notice (N) P descriptor file with the following long descriptions: G0076: Brief (20 minutes) care management home visit for a new patient. or use only in a edicareapproved enter for edicare & edicaid nnovation () model. (ervices must be furnished within a beneficiary s home, domiciliary, rest home, assisted living and/or nursing facility.) G0077: Limited (30 minutes) care management home visit for a new patient. or use only in a edicareapproved model. (ervices must be furnished within a beneficiary s home, domiciliary, rest home, assisted living and/or nursing facility.) G0078: oderate (45 minutes) care management home visit for a new patient. or use only in a edicare-approved model. (ervices must be G0079: omprehensive (60 minutes) care management home visit for a new patient. or use only in a edicare-approved model. (ervices must be furnished within a beneficiary s home, domiciliary, rest home, assisted living and/or nursing facility.) G0080: xtensive (75 minutes) care management home visit for a new patient. or use only in a edicare-approved model. (ervices must be

5 hared- ystem aintainers Type of ervice 1 (TO1) applies to these P B ontractors shall add P G G0085 to the N P descriptor file with the following long descriptions: G0081: Brief (20 minutes) care management home visit for an existing patient. or use only in a edicare-approved model. (ervices must be G0082: Limited (30 minutes) care management home visit for an existing patient. or use only in a edicare-approved model. (ervices must be G0083: oderate (45 minutes) care management home visit for an existing patient. or use only in a edicare-approved model. (ervices must be G0084: omprehensive (60 minutes) care management home visit for an existing patient. or use only in a edicare-approved model. (ervices must be furnished within a beneficiary s home, domiciliary, rest home, assisted living and/or nursing facility.) G0085: xtensive (75 minutes) care management home visit for an existing patient. or use only in a edicare-approved model. (ervices must be Type of ervice 1 (TO1) applies to these P ontractors shall add P G G0087 to the N P descriptor file with the following long descriptions: G0086: Limited (30 minutes) care management home care plan oversight. or use only in a edicareapproved model. (ervices must be furnished within a beneficiary s home, domiciliary, rest home,

6 hared- ystem aintainers assisted living and/or nursing facility.) B G0087: omprehensive (60 minutes) care management home care plan oversight. or use only in a edicare-approved model. (ervices must be Type of ervice 1 (TO1) applies to these P ontractors shall process NG O are anagement ome isits claims when this benefit enhancement is elected by the provider for the ate of ervice (O) on the claim, when the beneficiary is aligned for the submitted claim, and has the following P codes: O G0076 G0077 G0078 G0079 G0080 G0081 G0082 G0083 G0084 G0085 G0086 G0087 This shall apply to Type of Bill: 85, Revenue (Rev) odes: 96, 97, or The hared ystem aintainers (s) shall consider a beneficiary aligned if the from date on the date of service on the claim is on or after the effective start date and on or before 90 days after the effective end date The ommon orking ile () shall generate an nformational Unsolicited Response (UR) based on beneficiary file updates for are anagement ome isits when enhancement ndicator 7 is on the claim, using guidelines in based on 90 days after the effective end date. NOT: is updating the existing UR process to

7 hared- ystem aintainers include NG O benefit enhancement ndicator 7 for UR code B edicare contractors shall trigger claim adjustments, if necessary, based on receipt of the UR edicare contractors shall apply a rate for P codes listed below: G0076 G0077 G0078 G0079 G0080 G0081 G0082 G0083 G0084 G0085 G0086 G0087 NOT: The rate will be displayed in the annual Physician ee chedule update shall reimburse the lesser of the billed charge or P rate for ethod providers billing on Type of Bill: 85, Rev odes: 96, 97, or ontractors shall reject or return as unprocessable a claim line with P G G0087 that do not fall on or within the effective start date and effective end date of the provider on the Next Generation O participant or preferred provider file with benefit enhancement indicator 7 are anagement ome isits NOT: Refer to the 835 ealthcare Policy dentification egment (loop 2110 ervice Payment nformation R), if present. edicare contractors shall assign laim djustment Reason ode (R) 96 (Non-covered charge(s) with Remittance dvice Remark ode (RR) N83 (No appeal rights. djudicative decision based on the provisions of a demonstration project), along with

8 hared- ystem aintainers Group ode O (contractual obligation). B ontractors shall reject or return as unprocessable a claim line with P G G0087 that do not fall on or within the effective start date and effective end date and on or before 90 days after the effective end date of the beneficiary alignment NOT: Refer to the 835 ealthcare Policy dentification egment (loop 2110 ervice Payment nformation R), if present. edicare contractors shall assign R 96 (Noncovered charge(s) with RR N83 (No appeal rights. djudicative decision based on the provisions of a demonstration project), along with Group ode O (contractual obligation) ontractors shall display the following message on all NG-O are anagement ome isits claims: N essage 61.3 nglish You received this home visit service from your Next Generation ccountable are Organization (O) provider. You may have been able to receive this care because of your relationship with the O. sk your doctor to tell you more about your O. panish a recibido el servicio de visita a la casa de parte del proveedor de su nueva generación de organización responsable del cuidado de salud (O). s posible que recibió esta atención a causa de su relación con la O. Pregúntele a su médico que le diga más sobre su O ontractors shall process and flag NG O are anagement ome isits claims with benefit enhancement indicator 7 when this benefit enhancement is elected by the provider for the O on the claim, when the beneficiary is aligned for the submitted claim, and has one of the following P codes:

9 hared- ystem aintainers B G0076 G0077 G0078 G0079 G0080 G0081 G0082 G0083 G0084 G0085 G0086 G shall create a new reject at the claim level if the Beneficiary has a ome ealth pisode present with or without the OB/OLB and the ates of ervice with Benefit nhancement ndicator '7 for NG O is during the Beneficiary 's ome eath pisode edicare contractors shall reject or return as unprocessable a claim and assign laim djustment Reason ode (R) 96 (Non-covered charge(s) with Remittance dvice Remark ode (RR) N83 (No appeal rights. djudicative decision based on the provisions of a demonstration project), along with Group ode O (contractual obligation) The ingle Testing ontractor (T) shall provide to O-O the provider and beneficiary data to create the test files by eptember 18, 2018., s The O-O contacts are: Tej Ghimire: Tej.Ghimire@cms.hhs.gov and Yani ellacheruvu: Yani.ellacheruvu@cms.hhs.gov The O-O shall provide the provider alignment and beneficiary alignment test and final files to T on or before the week of October 16, 2018., T The O-O contacts are: Tej Ghimire: Tej.Ghimire@cms.hhs.gov and Yani ellacheruvu: Yani.ellacheruvu@cms.hhs.gov The edicare dministrative ontractors (s)

10 hared- ystem aintainers shall provide to O-O the provider and beneficiary data to create the test files on or about the week of October 30, B These sample beneficiaries and providers shall be provided in a single excel file using the layout of Ns, TNs, and NPs. The O-O shall provide a template of this xcel document. The O-O contacts are: Tej Ghimire: Tej.Ghimire@cms.hhs.gov and Yani ellacheruvu: Yani.ellacheruvu@cms.hhs.gov The O-O shall push the test files to the irtual ata enters (s) on or about the week of November 27, 2018 and transmit the test files with the s. The O-O contacts are: Tej Ghimire: Tej.Ghimire@cms.hhs.gov and Yani ellacheruvu: Yani.ellacheruvu@cms.hhs.gov The ingle Testing ontractor (T) shall provide to O-O the provider and beneficiary data to create updated test files by November 5, 2018., T, s The O-O contacts are: Tej Ghimire: Tej.Ghimire@cms.hhs.gov and Yani ellacheruvu: Yani.ellacheruvu@cms.hhs.gov The O-O shall provide to the ingle Testing ontractor (T) the provider and beneficiary data to create updated test files by November 16, 2018., T, s The O-O contacts are: Tej Ghimire: Tej.Ghimire@cms.hhs.gov and Yani ellacheruvu: Yani.ellacheruvu@cms.hhs.gov The edicare contractors shall bypass reason code 46#7 on Type of Bill (TOB) 11 when demonstration code 74 is present s shall adjust or reprocess claims that were previously denied or rejected for 46#7 that are brought to their attention ontractors shall use the following messages: R

11 hared- ystem aintainers laim djustment Reason ode (R) 132 and Group ode: O (ontractual Obligation) for all claims with the NG O reduction applied and no payment can be made because the calculated provider reimbursement amount is less than the cash deductible, coinsurance, and/or blood deductible amounts; to create a new finalized payment reason code to be assigned. B The R shall accept the new value 7 for are anagement ome isits. R. PROR UTON TBL Number Requirement Responsibility LN rticle: will make available an LN atters provider education article that will be marketed through the LN onnects weekly newsletter shortly after the R is released. s shall follow O Pub. No hapter 6, ection , instructions for distributing LN onnects information to providers, posting the article or a direct link to the article on your website, and including the article or a direct link to the article in your bulletin or newsletter. You may supplement LN atters articles with localized information benefiting your provider community in billing and administering the edicare program correctly. ubscribe to the LN atters listserv to get article release notifications, or review them in the LN onnects weekly newsletter. B. UPPORTNG NORTON ection : Recommendations and supporting information associated with listed requirements: N/ "hould" denotes a recommendation. -Ref Requirement Number Recommendations or other supporting information:

12 ection B: ll other recommendations and supporting information: N/. ONTT Pre-mplementation ontact(s): Karin Bleeg, Brede schliman, Post-mplementation ontact(s): ontact your ontracting Officer's Representative (OR).. UNNG ection : or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of ork. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. TTNT: 0