Effective January 1, 2022, the Centers for Medicare & Medicaid Services (CMS) will replace the No-Pay Request for Anticipated Payment (RAP) with a home health Notice of Admission (NOA). The No-Pay RAP was implemented in 2021 as part of the home health regulatory changes of Section 1895(b)(2) of the Social Security Act (the Act), as amended by Section 51001(a) of the Bipartisan Budget Act of 2018 (BBA of 2018) requiring Medicare to change the unit of payment under the Home Health Prospective Payment System (HH PPS) from 60 days to 30 days.
The announcement posted on the MLN Matters Number: MM12256 featured the updates to Chapter 10 of the Medicare Claims Processing Manual (CR 12256) to include instructions for submitting home health NOAs.
All About NOA
In a nutshell, while the RAP is filed every 30 days, the NOA is filed only once. It’s a one-time submission within five (5) days from the initial start-of-care (SOC) visit, which covers continuous 30-day periods of care until the patient is discharged from home health services.
- The appropriate physician’s written or verbal order that sets out the services required for the initial visit has been received and documented as required at 42 Code of Federal Regulations (CFR) Sections 484.60(b) and 409.43(d); and
- The initial visit within the 60-day certification period has been made and the individual is admitted to home health care (84 FR 60548)
- For all patients receiving home health services in 2021 whose services will continue in 2022, you should submit a NOA with a one-time, artificial “admission” date corresponding to the “From” date of the first period of continuing care in 2022.
- CMS only requires one (1) NOA for any series of home health periods of care (POCs) beginning with admission to home care and ending with discharge. Once you report a discharge to Medicare, you must send a new NOA before submitting any additional claims.
- Home health agencies must submit a NOA to their Medicare Administrative Contractor (MAC) within five (5) calendar days from the SOC date. Once again, the NOA is a one-time submission that establishes the home health POC and covers contiguous 30-day POCs until you discharge the individual from Medicare home health services.
Remember that the penalty for late submission of NOA starts from the first day of the 60-day episode of care or five (5) days after the initial visit, NOT the first day after the agency missed the deadline. A late NOA submission is penalized at 1/30th of the expected payment per day applied from the date of admission, which represents a potential loss of 20% or more. This will particularly affect you if non-billable visits reduce the full payment to a Low Utilization Payment Adjustment (LUPA).
The RAP value is only a 30-day period of time, where the NOA basically is from the beginning to the time that it is actually accepted. For instance, if the NOA is 45 days late next year, then the agency will be penalized for 45 days, not just 30.
Actionable Tips to Prepare for NOA 2022
Align your Revenue Cycle Management
Your clinical and revenue cycle teams should coordinate patient admissions and NOA timelines. Once a patient admission is completed, the billing team must be informed of the NOA submission and acceptance timeframe to avoid delays.
Improve documentation accuracy
Although not required for NOA submission, it is best to observe timely submission and review of the OASIS SOC to immediately identify the LUPA threshold and generate a HIPPS code reflective of the actual focus care and consistent with the HIPPS code for final claim.
Aside from a time-efficient review timeline, your QA/coding provider should also proactively help you track any lacking intake documentation. These are essential bases for the focus of care and primary diagnosis ICD-10 coding.
Stay on top of the Patient Admission Date
Always remember that the ‘From’ date on the claim (the first date of the payment period) is Day 0. For a NOA to be considered timely, it needs to be accepted by the MAC by Day 6, or five (5) days after the ‘From’ date.
NOTE: Generally, the Fiscal Intermediary Standard System (FISS) is not open on Sundays and holidays— this practically means that submission timelines can vary based on which day of the week the patient admission has been accepted. Refer to the timetable below assuming the agency submits a day before Day 5 (or the last day of timely acceptance).
Success in adjusting to this change weighs heavily on good practices, such as streamlining documentation, adhering to strict timelines, and adopting smarter, more efficient techniques. Agencies should continue to run effective, compliant operations, maximize the use of EMR tools, and continue to meet CoP requirements throughout the course of care. On the other hand, while quality documentation should be kept a priority, it is equally important for agencies to constantly improve patient care.