Home Health

MACs reminding agencies of RAP exception rules

Exceptions are allowed for RAPs approved outside of the five-day window in 2021, but agencies should include information in the remarks field indicating the reason the RAP was late, according to Medicare administrative contractor CGS.

Since January 1, 2021, agencies have five days from the start of care to get the RAP approved by their MAC or face stiff penalties (MM11855). There have been a number of system issues that have caused delays that were not the fault of agencies, but CGS stresses that exception requests need to come with explanations.

The “remarks” information must document how one of the four allowable circumstances qualify for an exception, according to the CGS alert.

Those allowed exceptions include:

  • Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the HHA’s ability to operate
  • An event that produces a data filing problem due to a CMS or MAC systems issue that is beyond the control of the HHA
  • A newly Medicare-certified HHA that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC
  • Other circumstances determined by the MAC or CMS to be beyond the control of the HHA

If the information provided is not clear or if the “remarks” field is blank, CGS tells providers in its 15 states that it will issue a non-medical review additional development request with reason code 7RMRK.

Agencies shouldn’t submit medical documentation. Instead, they should offer clear information that demonstrates one of the four circumstances for an exception.

For example, if the RAP was late due to a claims processing issue, document which issue caused the delay,” CGS noted. See more at cgsmedicare.com.