HETS to Fix Hospice Prior Benefit Period Identification Issue


Over the last several months, the announcement that CMS was phasing out eligibility information currently available through Direct Data Entry (DDE) next April has driven providers to eligibility reporting solutions using the CMS HIPAA Eligibility Transaction System (HETS).

“HETS to replace Common Working File (CWF) for eligibility inquiries”


“How to Get Connected – HETS 270/271”


The providers and vendors who were early adopters of this technology noticed differences in the data reported through these two systems.  Recently, I co-wrote an article for Health Data Management that described these systems, how they work, and the differences between them.  It is available on our blog or through this link:

“A Primer on the HIPAA Eligibility Transaction System”


One of the significant issues regarding the difference in DDE and HETS is related to hospice agencies and their requirement that they have a “face-to-face” visit with a patient prior to the third recertification period and for every subsequent benefit period.  DDE allows access to the Common Working File (CWF).  This file contains data regarding the last three hospice benefit periods for a Medicare patient and when they occurred.  It was simple for hospice agencies to determine if a face-to-face visit was required by looking at the number of previous hospice benefit periods in DDE.  Since the CWF is a fixed-length record system, each Medicare patient has three data elements for previous hospice benefit periods.  As a new benefit period occurs, new billing data is added to the CWF in the most recent benefit period column and previous data is moved over to the prior benefit periods.  This system allows the CWF to retain the last three benefit periods, in date order, regardless of how long ago they may have occurred.

HETS is a real time variable length system that returns all current data associated with a Medicare patient meeting the eligibility criteria requested in the ANSI 270 eligibility request transaction.  HETS has been designed to report all benefit periods and other billing data that have occurred in the last 27 months, regardless of the number of benefit periods.  This means that HETS will return all benefit periods in the last 27 months, not just the last three.  However, this also means that if a benefit period occurred over 27 months in the past, it would be omitted in the response and the subsequent ANSI 271 eligibility response transaction.

This presented a problem with hospice agencies because if one or fewer prior benefit periods were returned in the HETS response they might assume that no face-to-face was required because the next recertification would not be the third.  However, it was always possible that a benefit period may have occurred over 27 months ago and was unreported by HETS.  This might cause a hospice agency to provide services to the patient without the face-to-face, only to be denied reimbursement by Medicare after billing when it was determined that a face-to-face was required.

Not a week went by when I did not get two or three calls or emails from hospice agencies wanting to know how they could deal with this issue, especially after CMS retires the DDE screens next April which contained the only reliable method of checking for this billing requirement.

To try to help our customers with this issue, we submitted a request to the HETS help desk to make sure that they were aware of this problem and to try to see if a solution could be developed before next April. This question also referenced another outstanding issue, the patient status. This data element is available for prior billing periods through DDE, but it is not yet available in HETS.  We submitted this question about three months ago.  Here is the question we submitted:

“Does HETS 270/271 plan to add the patient status and patient indicator to the Home Health Prospective Payment System (PPS) episode information (as returned by Medicare legacy eligibility systems like HIQA and HIQH)? Currently, if a beneficiary is in continuous Home Health or Hospice episodes with a provider, this is reported as a single benefit period. Because of Medicare’s new face-to-face visit requirements, it is important for providers to know exactly which benefit period or episode the patient is in. Are there plans for HETS 270/271 to report these periods/episodes in the same manner as they are reported in HIQA and HIQH?”

We finally received a response on 8/20/13:

“The HETS 270/271 application is being modified to return the total number of hospice occurrences on a 271 response whenever STC 45 is requested on the 270.  This new data element will not be available in the 271 response until January 2014.  Once available, the total number of hospice occurrences will be returned in a separate 2110C loop on the 271 response.

The total number of hospice occurrences will be returned on the 271 response whenever STC 45 is requested on the 270 regardless of the beneficiaries Part A eligibility for the requested date or date range or the presence or absence of hospice benefit period data for the beneficiary returned on the 271 response.”

STC stands for Service Type Code and STC 45 is one of the standard codes sent by most vendor HETS applications for all types of providers when a HETS eligibility request is sent.  The 2110C loop is simply a new place where this information will stored when it is sent in the response, beginning next January.  The second paragraph states that this data element (prior hospice benefit periods) will be returned in the response even if the patient was not eligible for Medicare Part A on the date range for the eligibility request or even if no benefit period data is being returned in the request, meaning that it will include total benefit periods before the 27 month data reporting period, if they occurred.

Although the patient status issue is not yet addressed, it appears that the CMS HETS development team has found a way to retrieve all previous hospice benefit periods, regardless of age, and include the total number of prior benefit periods in the HETS database for responses.  Since it will be available in January, your HETS application vendors should have plenty of time to incorporate this new value in their HETS reports, screens and databases, before it is eliminated in DDE.

By Kalon Mitchell – President, MEDTranDirect, Inc.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s