Last Modified: 5/3/2024
Location: FL, PR, USVI
Business: Part A, Part B
If an acute care hospital determines the entire admission is non-covered and the provider is liable, bill as follows:
• Type of bill – 11X (Full provider liable claim)
• Admit date – Date the patient was actually admitted (not the deemed date)
• From & through dates - This span of dates should include all days
• Noncovered days - The entire length of stay should be entered as noncovered
• Occurrence span code M1 – The first provider liable day through the last provider liable day
• Revenue code - Room & board revenue code line report as follows:
• Total units should equal the total number of days
• Noncovered units should equal the total days
• Total charge should equal the rate times the total number of units
• Noncovered charge should equal the rate times the number of noncovered days
If an acute care hospital determines a portion of the admission is noncovered and the provider is liable, bill as follows:
• Type of bill – 11X
• Admit date – Date the patient was actually admitted (not the deemed date)
• From & through dates - This span of dates should include all days, both covered and noncovered
• Covered Days – The portion of the stay in which the patient received medically necessary services
• Noncovered days – The portion of the stay in which the provider is liable due to the services rendered were not medically necessary
• Occurrence span code M1 – The first provider liable day through the last provider liable day Revenue code - Room & board revenue code line report as follows:
• Total units should equal the total number of days
• Covered units should equal the total days minus the noncovered days (Provider Liable Days)
• Total charge should equal the rate times the total number of units
• Noncovered charge should equal the rate times the number of noncovered days
If an acute care hospital determines that a portion of the admission, or the entire admission, is noncovered and the beneficiary is liable, bill as follows:
• Type of bill – 11X
• Admit date – Date the patient was actually admitted (not the deemed date)
• From & through dates - This span of dates should include all days, both covered and noncovered
• Covered days – Report only days the patient was at a covered level of care. If the entire stay is noncovered, report zero covered days
• Noncovered days – Report all the days that are noncovered for the duration of the stay
• Occurrence span code 76 - The first beneficiary liable day through the last beneficiary liable day
• Occurrence code 31 – The date the facility provided notice to the beneficiary
• Value code 31 – The amount charged to the beneficiary for noncovered services
• Revenue code - Room & board revenue code line report as follows:
• Total units should equal the total number of days
• Covered units should equal the total days minus the noncovered days
• Total charge should equal the rate times the total number of units
• Noncovered charges should equal the rate times the number of noncovered days.
To assist us with understanding the reason for noncovered billing, you may include one of these recommended remarks:
• Benefits exhausted
• Direct Graduate Medical Education (DGME)
• Does not meet medical necessity for inpatient stay criteria
• Lower level of care, non-acute Care, non-skilled, MCR rejection or cardiac rehab
• Provider/beneficiary liable
• No Part A entitlement
• No pay, noncovered or non-billable procedure
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