Medicare Eligibility through HETS and the Hospice Notice of Election (NOE)

Medicare maintains a computer system dedicated to the processing of eligibility requests through the HIPAA ANSI 270/271 transactions designed for this purpose. The system is called HETS which stands for HIPAA Eligibility Transaction System. You can obtain more information about this system from their site:

This system is updated daily with information from the Common Working File (CWF) and other CMS systems to include current eligibility data and billing history for all current Medicare patients. This system is supported by the MCARE help desk. As one of the National Service Vendors for this system, we work closely with this organization to monitor reported issues and suggest enhancements. So far, they have done a very good job in dealing with the issues reported and correcting them.

The HETS software used to process these transactions is updated quarterly to fix reported issues and provide additional information required by providers for eligibility evaluation for Medicare patients. In particular, they are working to make sure that data available through the Medicare Direct Data Entry system, also referred to as FISS or DDE, is available through these transactions since CMS plans to retire this old mainframe user interface for obtaining this information.

Last year, this included adding psychiatric days to the results and expanding the provider types that can access the data and what data is returned by provider type.

MEDTranDirect works regularly with this organization to make sure that features requested by our customers are considered for these updates. Last October, CMS introduced new requirements for hospice agencies to report the NOE and NOTR within five days of the contractual event (admitting a patient, discontinuing services, and transfers). The only way that hospice providers can convey the NOE to CMS is through data entry in the DDE system. The provider then must monitor this system, account by account each day, to determine if the NOE was accepted. If it was, the NOE is considered timely if it was entered in the five day window. If it is rejected, then it must be reentered and monitored again with the new verification date being the date of the DDE NOE or NOTR entry that is eventually accepted.

Hospice providers must assess a penalty against themselves on the subsequent claim for these accounts based on the number of days the NOE is late based on 100% of the daily rate for each day late after the five day window. This makes monitoring this process vital for hospices. In addition, once a patient is accepted for hospice coverage, any bills sent by any other healthcare provider regarding services associated with the diagnosis related to the hospice service, after the NOE acceptance date, are rejected by Medicare.

We researched the processing of NOE’s through the DDE system and found that most of the time, this was reported in the HETS transaction as a hospice billing event and this data could be used by the hospice and other healthcare providers to verify that the patient was covered under hospice and which provider was currently responsible for providing this service. This procedure could also be used to verify the acceptance of the NOE and NOTR without looking up each account each day in DDE. However, we also found that approximately 20% of the time, this information was available in DDE, but never made it to the HETS transaction.

We originally reported this issue on October of last year. We monitored the issue through the MCARE help desk tracking system, but we were later informed that because the NOE was not officially a claim, it was not supported in the HETS transaction. We pointed out that most of the time, it was being processed like other claims and reported in the eligibility results, but to no avail.

Recently, we approached the help desk again with new documentation showing examples of NOE data that was showing up in HETS and data that was not. We also provided information from their own publications that showed how vital this information was in determining the eligibility status of Medicare patients and whether or not current services would be paid. We also pointed out that the status could only be determined by looking up each account individually in DDE and that if they intended to retire this service, there would be no way for a hospice to determine if the NOE was processed.

This appeared to do the trick. They are now actively working on resolving the issue to include NOEs in the HETS response reliably. Once this is done, hospice providers will be able to check these accounts in seconds and other providers will be able to reliably determine when patients are covered by hospice and who the provider is. We expect to see something in the upcoming update to resolve this issue. We will keep you informed on the status of this request through this blog. Once the data is corrected, it will be supported immediately in our HETS eligibility service.

By Kalon Mitchell – President, MEDTranDirect