The Notice of Admission (NOA) is the one filing that tells Medicare a home health admission has started. Under 42 CFR 484.205(j)(1), the agency must submit it to its Medicare contractor "within 5 calendar days after the start of care date." When it is late, the 30-day period payment is cut by 1/30th for each day counted from the start of care date, not from the day the NOA became late.
This page is for billers and owners asking how late is too late and what it costs. Which date is the start of care is in the start of care date explained. How a referral reaches that visit is in referral to first visit.
Quotations are from 42 CFR 484.205(j), the Medicare Claims Processing Manual, chapter 10 (section 10.1.10.3 unless another section is named), and the CY 2022 home health PPS final rule at 86 FR 62288 to 62289.
One NOA Per Admission
The regulation: "The NOA is a one-time submission to establish the home health period of care and covers contiguous 30-day periods of care until the individual is discharged from Medicare home health services." The manual adds: "After a discharge has been reported to Medicare, a new NOA is required before the HHA submits any additional claims."
So the second 30-day period does not need a new NOA. Neither does a recertification. A recert starts a new 60-day certification period, not a new admission.
The NOA also records your agency as the primary home health agency (section 20). And per section 40.2, "Claims submitted before an NOA has been received for the beneficiary will be returned to the provider."
When You Can File It
484.205(j)(2) sets two conditions:
"(i) Once a physician or allowed practitioner's written or verbal orders that contains the services required for the initial visit have been received and documented as required at §§ 484.60(b) and 409.43(d) of this chapter. (ii) The initial visit must have been made and the individual admitted to home health care."
That is the whole list. A completed OASIS and a signed plan of care are not on it. The 2020 RAP rule in the same section, 484.205(h)(1), did require the OASIS to be "complete, locked or export ready." The NOA does not.
Practice, not rule: file the NOA the same day the start of care visit is done. Both conditions are met at that point, and the regulation asks for nothing else.
The Five-Day Window: Which Day Is Day Zero
The manual's version of the deadline: "A timely-filed NOA is submitted to and accepted by the A/B MAC (HHH) within five calendar days after admission date." Its glossary (section 10.1.24) defines the admission date as "the date of the first service delivered by the HHA."
The start of care date is day 0, not day 1. The CY 2022 final rule gives the count:
| Date | Day | What CMS says |
|---|---|---|
| January 1, 2022 | Day 0 | The start of care, the first day of the first 30-day period |
| January 6, 2022 | Day 5 | "An NOA submitted on or before this date would be considered 'timely-filed'" |
| January 7, 2022 and after | Day 6 and later | "An NOA submitted on and after this date would trigger the penalty" |
"Calendar" means a Saturday counts the same as a Tuesday. Where the manual means business days, it says so. "Accepted" is the manual's word: the NOA has to be "submitted to and accepted by" the contractor inside the window. The regulation speaks only of the "date of filing."
Dark days rarely matter, because "the receipt date is typically applied to the NOA immediately upon submission" (section 40.2). An NOA sent the day before a dark day period that got no receipt date until after it earns an exception when documented, but "CMS expects these cases to be very rare."
How the Late Penalty Is Calculated
When the NOA is not filed "within 5 calendar days after the start of care," 484.205(j)(3) applies five consequences:
| Consequence | The regulation's words, 42 CFR 484.205(j)(3) |
|---|---|
| Unpaid days | (i) "Medicare does not pay for those days of home health services from the start date to the date of filing of the notice of admission" |
| The 1/30th cut | (ii) "The wage and case-mix adjusted 30-day period payment amount is reduced by 1/30th for each day from the home health start of care date until the date of filing of the NOA" |
| LUPA periods | (iii) "No LUPA payments are made that fall within the late NOA period" |
| The cap | (iv) "The payment reduction cannot exceed the total payment of the claim" |
| Who carries it | (v) "The non-covered days are a provider liability" and "The provider must not bill the beneficiary for the non-covered days" |
The manual states the arithmetic. Medicare "shall reduce the payment for a period of care, including outlier payment, by the number of days from the home health admission date to the date the NOA is submitted to, and accepted by, the A/B MAC (HHH), divided by 30."
The part that catches agencies is where the count begins. The CY 2022 final rule: "the penalty calculation would begin with the start of care date of January 1, 2022, counting as the first day of the penalty."
Warning
A late NOA is not charged only for the days after day 5. Once the NOA misses the window, the count runs from the start of care date itself, so the days inside the window are charged too. Missing by a day is not a one-day penalty.
The dollar figure shows on the remittance as value code QF, "Late-filed NOA penalty amount" (section 40.2).
Submitted Is Not Accepted: Errors and Returned NOAs
An NOA sent early with a bad beneficiary identifier can still end up late. The manual says an NOA with "inadvertent errors (such as a beneficiary identifier that has recently changed)" may not be "immediately returned to the HHA for correction," and those delays "may qualify for an exception."
Contractors "shall grant an exception for the late NOA" when the agency documents:
- "When the original NOA was submitted"
- "When the NOA was returned for correction or was accepted and available for correction"
- That it "resubmitted the returned NOA within two business days of when it was available for correction," or cancelled an accepted NOA and resubmitted on the same two-business-day clocks
The identifier has its own limit. Contractors "will not grant exceptions based on MBI changes that were accessible to the HHA more than two weeks prior to the admission date." The manual's fix is "an eligibility check immediately before admission."
Section 40.2 adds that contractors "shall not grant exceptions" when "the HHA can correct the NOA without waiting for Medicare systems actions," or for "a partial NOA."
The Exceptions, and How to Ask for One
Under 484.205(j)(4), "CMS may waive the consequences of failure to submit a timely-filed NOA." The agency "must fully document and furnish any requested documentation to CMS for a determination of exception. An exceptional circumstance may be due to, but is not limited to the following":
"(A) Fires, floods, earthquakes, or similar unusual events that inflict extensive damage to the home health agency's ability to operate. (B) A CMS or Medicare contractor systems issue that is beyond the control of the home health agency. (C) A newly Medicare-certified home health agency that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its Medicare contractor. (D) Other situations determined by CMS to be beyond the control of the home health agency."
The request travels on the claim, not the NOA. Section 40.2: "append modifier KX to the HIPPS code reported on the revenue code 0023 line," and use Remarks to "enter information supporting the exception category that applied to the NOA." The proof "should consist of printouts or screen images of any Medicare systems screens."
Tip
Practice, not rule: save a screen image of each NOA's submission and receipt date the day it goes in. The claim that carries the exception request is sent "at the end of the 30-day period, or after the patient is discharged, whichever is earlier" (section 10.1.10.4), weeks later.
Transfers, Readmissions and Payer Changes
| Situation | What to file | Source |
|---|---|---|
| New admission | NOA, type of bill 032A. The From, Through and Admission dates are all "the date of the first visit provided in the admission" | Manual 40.1 |
| Next 30-day period or recertification, no discharge | Nothing new. The one-time NOA covers it | 42 CFR 484.205(j)(1) |
| Patient transfers in from another agency | NOA with condition code 47 | Manual 10.1.13, 40.1 |
| Discharged, then readmitted to your agency in the same 30 days | A new NOA, allowed when "the CMS certification number (CCN) on the new NOA matches the CCN on the prior period" | Manual 10.1.14 |
| Hospital stay, patient not discharged, returns in the same 30 days | Nothing new. Per the manual, "the same period of care continues" | Manual 10.1.14 |
| Medicare Advantage to Original Medicare | A new start of care OASIS, then an NOA dated from "the first visit provided after the Original Medicare effective date" | Manual 10.1.23 |
| NOA sent in error | Cancel with type of bill 032D | Manual 40.1, 30.11 |
On a transfer, the receiving agency must document that it "accessed a Medicare inquiry system" and "contacted the initial HHA on the effective date of transfer." Without condition code 47, an NOA that lands in another agency's open admission period "will be returned to the provider because the HHA is not the primary HHA for that beneficiary" (section 30.6).
The manual's timeliness sentence is not limited to first admissions: "NOAs must be submitted timely."
The NOA itself is not paid. Agencies "receive a single payment for a 30-day period of care after the final claim is submitted" (484.205(g)(4)), at the rates in the 2026 visit rates guide.
Key Takeaways
- Five calendar days after the start of care date, which is day 0. In CMS's example, January 1 makes January 6 the last timely day.
- Timely means accepted by the contractor in the window. A returned NOA is saved by a Medicare systems delay plus resubmission within two business days.
- Late means 1/30th of the period payment, outlier included, for each day counted from the start of care date. Capped at the claim's total. Never billed to the patient.
- One NOA per admission. File a new one after a reported discharge, on a transfer in (condition code 47) and on a switch from Medicare Advantage.
- Exceptions are narrow and documented. Ask on the claim, with modifier KX and remarks.
Frequently asked questions
How many days does a home health agency have to file the Notice of Admission?
Five calendar days after the start of care date, under 42 CFR 484.205(j)(1). The start of care date is day 0. In CMS's own example, a start of care on January 1 makes January 6 the last timely day, and an NOA submitted on January 7 or later triggers the penalty.
How is the late NOA penalty calculated?
The 30-day period payment, including any outlier payment, is reduced by 1/30th for each day from the start of care date until the NOA is filed. The count starts on the start of care date, not on the first late day. The reduction cannot exceed the total payment of the claim, and the agency must not bill the patient for it.
Do I need a new NOA for each 30-day period or recertification?
No. The NOA is a one-time submission that covers contiguous 30-day periods until the patient is discharged from Medicare home health. A new NOA is needed after a discharge has been reported, and a patient transferring in from another agency needs an NOA with condition code 47.
Can the NOA be filed before the OASIS is complete?
Yes. The regulation has two conditions: orders containing the services for the initial visit have been received and documented, and the initial visit has been made and the patient admitted. A completed OASIS and a signed plan of care are not on the list.
What counts as an exception to the late NOA penalty?
The regulation lists fires, floods, earthquakes or similar events that badly damage the agency's ability to operate; a CMS or Medicare contractor systems issue; a newly certified agency notified after its certification date or still awaiting its user ID; and other situations CMS finds beyond the agency's control. The agency must document it.
Does an NOA that was returned for an error still count as timely?
Only when Medicare systems held it up. The manual tells contractors to grant an exception when the agency shows when it first submitted, when the NOA was returned or available for correction, and that it resubmitted within two business days. Errors the agency could fix without waiting do not qualify.
Sources
- 42 CFR 484.205, Basis of payment: (j)(1) the 5-day window and the one-time submission, (j)(2) the two filing conditions, (j)(3) the consequences of a late NOA, (j)(4) the exceptions, (g)(4) payment on the final claim, and (h)(1) the 2020 RAP conditions used for comparison. Fetched from Cornell LII.
- CMS, Medicare Claims Processing Manual, Chapter 10, Home Health Agency Billing (Rev. 13089, issued 02-21-25): section 10.1.10.3 "Submission of the Notice of Admission (NOA)," 10.1.10.4, 10.1.13 transfers, 10.1.14 discharge and readmission, 10.1.23 payment source changes, 10.1.24 glossary, 20 and 30.6 primary HHA, 30.11, 40.1 NOA data elements, and 40.2 value code QF, modifier KX, remarks and the exception limits.
- CMS, CY 2022 Home Health Prospective Payment System final rule, 86 FR 62240 (November 9, 2021), NOA discussion and the day-count example at 86 FR 62288 to 62289.
- Related on this site: the start of care date explained, referral to first visit, tracking 60-day certification periods, CMS home health visit rates for 2026.