Know Your Hospice Cap Appeal Rights

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 6400, Hospice Cap Calculations Letters and Administrative Appeals, updating subsection 80.3 of the Medicare Claims Processing Manual, which describes the hospice administrative appeals process.

Hospice end of life care payment is subject to two statutory caps: a cap on payments for inpatient days, described in section 1861(dd)(2)(A)(iii) of the Social Security Act, and an aggregate cap on total payments, described in section 1814(i)(2)(A)-(C). CMS regulations require the contractor to notify each hospice provider in writing of the program reimbursement cap determinations for the cap year, whether the hospice has exceeded either cap. The hospice must refund any payments exceeding either cap to Medicare.

Each program reimbursement determination provides information describing the provider’s appeal rights. Depending on the controversial amount, the hospice may file an appeal for the contractor ($1,000 or more, but less than $10,000) or the Provider Reimbursement Review Board (PRRB) ($10,000 or more) to review, if:

  • Either cap amount has not been properly determined; or
  • Payments have not been properly determined; or
  • They are otherwise dissatisfied with the program reimbursement determination.

Appeal requests must be in writing and filed within 180 days of the program reimbursement determination date. See 42 CFR section 418.311 and 42 CFR part 405 subpart R for details.

Download the CMS Transmittal 1708 for more information about the hospice cap calculations and administrative appeals changes, which go into effect July 1.


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