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Last Modified: 5/15/2020 Location: FL, PR, USVI Business: Part A

Inpatient hospital entitlement changes FAQs

Q: My patient enrolled in a Medicare Advantage (MA) plan during the middle of the inpatient hospital stay. Who should I bill?
A: When a patient enrolls in or disenrolls from a MA plan during his/her inpatient stay, the following factors will determine whether to bill the MA plan and/or “traditional” Medicare.
1. The hospital provider receives prospective payment system (PPS) payments, or is exempt from PPS payments, or is a non-PPS provider; and
2. The date of enrollment/disenrollment with the MA plan
Inpatient PPS provider billing guidelines
The patient’s entitlement status at admission determines liability for inpatient acute care hospitals, inpatient rehabilitation facilities (IRFs), or long-term care hospitals (LTCHs) that receive PPS payments.
If the patient was not enrolled in the MA plan at the time of admission and enrolls before discharge:
Bill the entire inpatient stay to Medicare for payment
MA organization is not responsible for payment
If the patient is enrolled in an MA plan at the time of admission and disenrolls before discharge:
Bill the entire inpatient stay to MA plan for payment, and,
Submit a no-pay claim to Medicare to report the patient’s inpatient utilization days
Exempt PPS inpatient provider billing guidelines
Providers that are inpatient children hospitals, cancer hospitals, and psychiatric hospitals/units exempt from PPS must split bill the appropriate coverage portion of the patient’s inpatient stay with Medicare and MA plan.
The patient is admitted on September 28 and discharged October 13, and enrolls in an MA plan effective October 1. Split bill as follows:
Bill Medicare for dates of service September 28 through September 30; and,
Bill MA plan for dates of service October 1 through October 13, and include necessary supporting documents; and
Submit a no-pay claim to Medicare for dates of service October 1 through October 13 to report the patient’s inpatient utilization days
Non-PPS inpatient provider billing guidelines
Inpatient hospitals that do not receive PPS payments must also split bill, and may only bill the MA plan for dates of service that fall within the coverage period enrollment and disenrollment dates.
Source: CMS internet-only-manual, publication 100-04, Chapter 1 external pdf file, section 90
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