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NHIC Audits

To: NHPCO Members
From: NHPCO Health Policy Team
Date: January 9, 2013

In mid-December, NHPCO began receiving calls from hospices in the J-14 MAC jurisdiction that there was new activity requesting ADRs from hospices for some type of edit. In following up with both NHIC and NGS, NHPCO asked for more information on the edits and asked that NHIC put out information for providers so that affected providers will know the details of the edits. The information below has been approved by NHIC for distribution to hospice providers in the NHIC jurisdiction. If there are questions about the edits or how your hospice has been impacted, please see the NHIC Customer Contact Center information at the end of this memo.

The NHPCO Regulatory team will continue to work proactively with NHIC and NGS and welcomes your additional feedback about the audits and the medical review process.

Hospice Medical Review Audits Implemented in December 2012

NHIC, Corp Medical Review implemented three new hospice widespread Targeted Medical Review (TMR) edits in December 2012. Below is a description of the edits that are currently in place.


Edit #


Certification Period

Measurement % Rate


Hospice length of stay (LOS) Day 1-200

First Certification Period

5% of all claims billed


Hospice LOS Day 1-200

Hospice LOS Day 1-200

10% of all claims billed


Hospice LOS

Third Certification Period

15% of all claims billed

These edits are widespread, which means that NHIC, Corp. is not targeting a particular provider; they are looking at a particular service. For example, Edit #5AH2A was put into the system to capture claims that are billed for the first certification period, with a LOS 1-200 days. Any provider who bills a claim that meets this requirement could receive an additional documentation request (ADR) from the system. The system will generate ADRs on 5% of all claims billed meeting the criteria for the edit. For example, if 100 claims are submitted that meet the criteria for edit 5AH2A- the system will randomly generate an ADR for five claims.

NHIC, Corp. Medical Review is auditing provider documentation to ensure that Medicare coverage requirements are being met during three different certification periods. Since the ADRs are generated based on meeting the criteria of the edit, some providers may experience a heavier ADR request than other providers. If a provider is a very large facility and bills a lot of claims, they could be subject to receive more ADRs than a hospice provider who is a smaller biller.

For help or for more information:

Providers should call the NHIC Customer Contact Center at (866) 289-0423 for assistance. All calls must be initiated through NHIC’s Customer Care Center so they can be tracked.