National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

MMR-2007 08A, August 2007

Clarification of Skilled Nursing Facility (SNF) Billing Requirements for Beneficiaries Enrolled in Medicare Advantage (MA) Plans (MM5653)

Provider Types Affected
Skilled Nursing Facilities (SNF) billing either a Medicare Administrative Contractor (A/B MAC) or fiscal intermediary (FI) for SNF services provided to Medicare beneficiaries enrolled in a Medicare Advantage (MA) plan

Provider Action Needed
This article is based on Change Request (CR) 5653, which clarifies the Medicare billing requirements for beneficiaries enrolled in MA Plans. CR5653 reminds SNFs (and Swing Bed (SB)) providers of the need to submit claims for such beneficiaries enrolled in MA plans and receiving skilled care in order to take benefit days from the beneficiary and/or update the beneficiary’s spell of illness information in Medicare systems.

Background
This instruction incorporates SNF billing requirements for beneficiaries that are enrolled in MA plans into the Medicare Claims Processing Manual. SNF providers must submit bills for beneficiaries enrolled in MA plans and receiving skilled care in order to take benefit days from the beneficiary and/or update the beneficiary’s spell of illness in the Medicare’s Common Working File (CWF) System.

In addition, Medicare is making system changes to allow hospital qualifying stay edits to be overridden by contractors. This change is necessary in case of a disaster or emergency-related situation, or some other circumstance indicated by the Centers for Medicare & Medicaid Services (CMS), which requires special processing of claims.

Key Points of 5653
Be aware that if a Medicare beneficiary chooses an MA plan as their form of Medicare, he/she cannot look to traditional “fee-for-service” Medicare to pay the claim if the MA plan denies coverage. SNF providers will apply the following policies to MA beneficiaries who are admitted to a SNF:

• If the SNF is nonparticipating with the plan, the beneficiary must be notified of their status because they are private pay in this circumstance.
• If the SNF is participating with the plan, pre-approve the SNF stay with the plan.
• If the plan denies coverage, appeal to the plan, not to the “fee-for-service” FI or A/B MAC.
• Count the number of days paid by the plan as Part A days used. (This counts as part of the beneficiary’s 100 days of Medicare SNF benefits.)
• Submit a claim to the “fee-for-service” FI or A/B MAC to take benefit days from the CWF records. (Note: The MA plans do not send claims to Medicare for SNF stays). Failure to send a claim to the FI or A/B MAC will inaccurately show days available.
• Submit the claim using bill type 18X or 21X and include a HIPPS code (use default code AAA00 if no assessment was done), room and board charges and condition code 04 (informational only bill).

Note: If the beneficiary drops their MA plan participation, beneficiaries have the balance of their 100 SNF days available to use under Medicare fee-for-service.

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5653) issued to your Medicare FI or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1290CP.pdf on the CMS Web site.

If you have questions, please contact your Medicare FI or A/B MAC at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site .

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5653
Pub. 100-4, Transmittal# R1290CP, CR# 5653
Related CR Release Date: July 13, 2007
Effective Date: January 1, 2008
Implementation Date: January 7, 2008