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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

Hospice Notice of Election (NOE) and Notice of Termination/Revocation (NOTR) and Clarification of Site of Service Codes Q5003 and Q5004

August 29, 2014 05:01 PM

On Friday, August 22, 2014, the Centers for Medicare & Medicaid Services (CMS) released Change Request 8877/Transmittal 3032: Hospice Manual Update for Diagnosis Reporting and Filing Hospice Notice of Election (NOE) and Termination or Revocation of Election.  CR8877 provides instruction to hospices and MACs on processing NOEs and NOTRs, exceptions to timely filing requirements for these notices, and provides clarification on site of service codes Q5003 and Q5004.

As finalized by CMS in the FY2015 Final Rule, timely-filed hospice NOEs shall be filed by the hospice and accepted by the Medicare administrative contractor (MAC) within 5 calendar days after the hospice admission date.  A timely-filed NOTR shall be filed by the hospice and accepted by the MAC within 5 calendar days after the hospice discharge/revocation date unless a final hospice claim has been filed. An NOTR does not need to be completed in cases where the patient is discharged due to death. 

In cases when the NOE is not timely filed, a hospice is responsible to provide care and not charge the beneficiary for any days of hospice care from the hospice admission date to the date the NOE is submitted to, and accepted by, the Medicare contractor. Hospices will report these non-covered days on the claim with an occurrence span code 77, and charges related to the level of care for these days will be reported as non-covered, or the claim will be returned to the provider (RTP).  There is currently no consequence to a hospice for not timely filing the NOTR. 

There are four possible exceptions to the timely filing of an NOE.  The hospice must request the exception.  If it is approved the provider liable days are waived. The four circumstances that may qualify the hospice for an exception to the consequences of filing the NOE more than 5 calendar days after the hospice admission date are as follows:

  1. fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s ability to operate;
  2. an event that produces a data filing problem due to a CMS or Medicare contractor systems issue that is beyond the control of the hospice;
  3. a newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its Medicare contractor; or,
  4. other circumstances determined by the Medicare contractor or CMS to be beyond the control of the hospice.

Regardless of the reason a hospice is requesting an exception, the hospice shall file the associated claim with occurrence span code 77 used to identify the non-covered, provider liable days. The hospice shall also report a KX modifier with the Q HCPCS code reported on the earliest dated level of care line on the claim. The KX modifier shall prompt the Medicare contractor to request the documentation supporting the request for an exception. Based on that documentation, the Medicare contractor shall determine if a circumstance encountered by a hospice qualifies for an exception.

If the request for an exception is approved by the Medicare contractor, the Medicare contractor will process the claim with the CWF override code and remove the submitted provider liable days, which will allow payment for the days associated with the late-filed NOE. If the Medicare contractor finds that the documentation does not support allowing an exceptional circumstance, the Medicare contractor will process the claim as submitted. It is important to note that CMS has identified that due to a systems limitation, remittance advice remark code N211 (you may not appeal this decision) will be applied to the provider liable days in error. These days are appealable and CMS plans to release a correcting change request in the future.

CMS provided instructions to MACs to approve requests for exceptions in cases where sequential billing requirements necessitate a second hospice provider removing its timely-filed NOE and any claims so that a previous provider can bill. Upon resubmitting the NOE, the second provider’s NOE would appear to the system to be filed late when in fact it wasn’t. In these scenarios, the hospices that had to back out its NOE should file the claim with KX modifier and the occurrence span code 77 as required.  The MAC should then approve the request once it has received the required documentation and process the claim without the provider liability days. 

CMS reiterated that hospice personnel issues; internal IT systems issues that the hospice may experience; the hospice not knowing the requirements; and failure of the hospice to have back-up staff to file the NOE do not qualify as exceptional circumstances.

In addition to the NOE and NOTR instructions, CMS provided clarification of how to use site of service codes Q5003 and Q5004.  Q5004 shall be used for hospice patients in a skilled nursing facility (SNF), or hospice patients in the SNF portion of a dually-certified nursing facility. There are 4 situations where CMS indicates this would occur:

  1. If the beneficiary is receiving hospice care in a facility that is only certified as a SNF (it is not dually certified).
  2. If the beneficiary is receiving general inpatient care in the SNF.
  3. If the beneficiary is in a SNF receiving SNF care under the Medicare SNF benefit for a condition unrelated to the terminal illness and related conditions, and is receiving hospice routine home care; this is uncommon.
  4. If the beneficiary is receiving inpatient respite care in a SNF.

If a beneficiary is in a nursing facility but doesn’t meet the criteria above for Q5004, the site shall be coded as Q5003, for a long-term care nursing facility.

CMS manuals will be updated to reflect these instructions.  The clarification of the site of service codes, per CMS, is not a change in policy and hospices should begin following these clarified definitions now.  The NOE and NOTR requirements go into effect on October 1, 2014.  Hospices should be submitting the NOE as soon as possible after admission now but there will be no consequences for late filing until October. 

Some hospices have reported attempts to file a NOTR now that has resulted in a rejection.  The Hospice Association of America (HAA) understands this issue is being addressed and it is expected that hospices will be able to file the NOTR without rejection by October 1, 2014.


  1. Begin filing the NOE as soon as possible after admission but no later than 5 days after admission now in order to avoid unforeseen issues in accomplishing this after October 1
  2. Ensure adequate plans and processes (i.e. back up staffing) are in place to ensure timely filing of the NOE and NOTR
    Reminder:  the NOE can only be submitted via DDE, mail or messenger.  Therefore, each hospice should have a back-up plan for submission if its DDE submission capabilities are interrupted. 
  3. Ensure appropriate use of the Q5003 and Q5004 site of service HCPCS codes now.  This may require modification to existing policies and processes for patients residing in dually-certified facilities.  For instance, the hospice will need to know which portion of the building the patient resides in. 

NAHC does have some outstanding questions for CMS and the MACs regarding CR8877 and will be sharing answers with members as we receive them.




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