Is Your Billing Team Ready for NOAs (Notice of Admissions) in 2023?
With NOAs, we witnessed three major issues. To begin with, many EHRs were not prepared to meet the new requirements. To prevent late filings and penalties, agencies were being forced to manually enter NOA data directly into the DDE system. This forced agencies to keep track of due dates and submission dates manually to ensure they didn’t miss anything. Second, MACs encountered difficulty with processing and status updates. Workarounds were suggested, with fixes planned for the future. Finally, there was a problem with missing data. Agencies had to, for example, add the four-digit routing code at the end of a zip code. All of this added to the workload and caused issues for agencies. It also put them in jeopardy if they didn’t remain on top of it.
From RAP to NOAThe Request for Anticipated Payment (RAP) was replaced by a Notice of Admission (NOA) starting January 1, 2022. Within five calendar days from the start of care, home health agencies must submit a NOA to their Medicare Administrative Contractor (MAC) or be subject to a non-timely submission fee.
Here’s everything that you need to know to be prepared including:
- What is a Notice of Admission (NOA)
- How to submit a NOA
- 5-day filing deadline details
- And more
Let’s dive in.
What is a Notice of Admission (NOA)?
A Notice of Admission or NOA is a one-time notification for a series of home health periods of care (HH POCs). It is basically an extension of the no-pay RAPs, which goes back to the reduced RAPs that started back in 2020.
Only one NOA is required for a series of HH POCs. It must be submitted at the beginning of the first 30-day payment episode, within five days of the start of care. The NOA establishes the patient and remains active until a discharge is submitted for that patient. However, once a discharge is submitted to Medicare, a home health agency must submit a new NOA in order to send and receive payment for any additional claims.
CMS has outlined changes, in detail, to Chapter 10 of the Medicare Claims Processing Manual, including instructions for submitting Home Health NOAs instead of RAPs on and after January 1, 2022.
The History of RAPs and NOAs
When CMS implemented the No-Pay RAP in January 2021, home health agencies experienced significant change related to cash flow. Most notably, after transitioning from 60% of the anticipated payment upfront to 20% in 2020, upfront payments were completely phased out in 2021. This put many agencies in a bind because they no longer received cash upfront to cover the cost of care. Agencies also experienced penalties from late submissions.
Another change was that agencies were required to submit a No-Pay RAP for each 30-day period of care. However, if an agency knew that a patient would continue care into a second 30-day period, they could submit both RAPs at the same time. At this time, the billing team at HealthRev Partners is billing both RAPs at the same time.
CMS initially intended to replace No-Pay RAPs with NOAs in January 2021, and the details were part of the Final Rule for Home Health PPS released in 2020. However, the transition was postponed due to comments submitted by stakeholders within the industry. Your comments matter! Learn more about how you can influence CMS policies.
NOAs went into effect January 1, 2022. The NOA eliminates submitting No-Pay RAPs.
What is needed to submit a NOA?
The NOA can be submitted with just two pieces of information. First, you need a written or verbal doctor’s order that identifies the skills necessary for the first visit. Secondly, you need to complete the first visit.
The NOA eliminates the need to submit a valid diagnosis code and HIPSS code.
What if Medicare isn’t the primary insurance?
Even if Medicare isn’t the patient’s primary insurance, we recommend that you still send a NOA. Our rule of thumb is to always submit the NOA so that it is on file with Medicare. In that case, if the payer is changed, we’ve already established care with Medicare and can release the final claim.
Note that if Medicare does become primary, OASIS documentation is also required.
How do I submit a NOA?
NOAs can be sent to your MAC by mail, Electronic Data Interchange (EDI), or through the Direct Data Entry (DDE) system. For more information specific to your MAC, please visit their website.
CR 12256 adds new information to Chapter 10 of the Medicare Claims Processing Manual, including detailed NOA filing procedures and amended billing instructions.
What Type of Bill (TOB) will be required?
NOAs should be sent using a TOB 32A. Use TOB 329 for Periods of Care (POCs) after you submit the NOA. According to CMS, “the National Uniform Billing Committee (NUBC) has redefined TOB 329 to represent an original claim, rather than an adjustment, for all claims with “From” dates on or after January 1st, 2022.”
How was continuing care from 2021 into 2022 handled?
For patients who received care in 2021 and continued receiving care into 2022, home health agencies should have filed a NOA for the first period of continuing care in 2022. The agency should have set an artificial start date for the first initial visit. That artificial admit date needed to be kept for all subsequent episodes until the patient was discharged. For example, if a patient was admitted to home health in 2021, but their care continued into 2022, the biller needed to manually enter that into the Medicare system and the admit date must have matched the episode start date to initiate the NOA in 2022. Then any final claim billed for episodes in 2022 also needed to have the admit date edited to match the NOA to be processed.
Once a patient is discharged, that NOA is no longer valid. If that same patient is admitted for services again, a new NOA is required. Before submitting any subsequent claims, you must transmit a fresh NOA to Medicare after reporting a discharge.
How do we ensure that no NOA is missed so we don’t miss out on revenue?
Our billers stopped submitting second 30-day RAPs for admissions with starts of care beginning on December 2nd, 2021 because they would fall in 2022. We manually keyed in these NOAs because the admit date wasn’t going to roll over.
Is there still a 5-day filing deadline?
No-pay RAPs were phased out of Medicare. The manual also removes references to 60-day HH PPS episodes and RAPs from the documentation. However, these changes did not relieve home health agencies of a 5-day filing deadline with steep fines if it’s missed.
NOAs received after day 5 will automatically receive a reduction in pay from the episode start date at 1/30th of the expected reimbursement. So, for example, a NOA received on day 6 would receive a penalty of 6/30th (or 1/5th) the expected reimbursement amount.
Within 5 calendar days following the start of care, home health agencies must submit a NOA to their MAC. The NOA is a single submission that sets the HH POC and covers consecutive 30-day POCs until the patient is discharged from Medicare home health services.
What if we miss the 5-day submission deadline?
Your agency will need to manually enter the NOA into the DDE system when you notice that the NOA is not on file with Medicare. If you do not submit your NOA within 5 calendar days of the commencement of care, you will be charged a non-timely submission fee.
The payment amount will be reduced by 1/30th of the wage-adjusted, 30-day period payment amount for each day that it’s late, counting from the start of care date to the date the NOA is submitted or the patient was discharged if an NOA is not submitted.
Can I file an exception request if I miss the 5-day submission deadline?
Yes, the exception will be added on the final claim as a conditional request. However, late NOA submission does not automatically approve you for an exception. There must be a valid reason the exception is being requested based on Medicare late submission criteria. If you fail to timely file the NOA, you may request an exception. If approved, the late submission fee will be waived. The four circumstances that may qualify for an exception are listed on these manual instructions.
Please make sure that your billing department is up to date on these manual changes.
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