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Last Modified: 9/28/2019 Location: FL, PR, USVI Business: Part A

Claims overlap FAQs

Q: I contacted the skilled nursing facility (SNF) and asked them to update the patient status on their claim, but they stated that the patient’s benefits are exhausted, and that the SNF is not responsible for paying the services. What should I do?
A: You must determine if the services were provided during the covered period of the SNF Part A stay or after the benefits exhausted, since consolidated billing rules may or may not apply. The SNF is required to bill “benefits exhaust” and/or “no pay” claims until the patient is discharged from the facility. In order to bypass Medicare edits, refile your corrected claim after the SNF has submitted or corrected their claims. In addition, it is recommended that you work with the SNF to help determine if the patient’s services were provided during the covered or non-covered portion of the stay and for claims resolution since timely filing rules apply.
Scenarios:
Services were provided during the SNF covered Part A stay
SNF consolidated billing rules apply
Services were provided after the benefits exhausted
SNF is only responsible for billing physical, occupational, and speech therapy services
All other services may be billed directly to the Medicare administrative contractor (MAC)
Services were provided after the patient was discharged
All services may be billed directly to the MAC
Benefits Exhaust
The SNF is only responsible for billing physical, occupational, and speech therapy services received during a non-covered stay. The beneficiary’s non-covered stay may be due to Part A benefits being exhausted, post hospital stay or the beneficiary did not meet SNF level of care requirements.
SNF Consolidated Billing
The consolidated billing requirements confer on the SNF’s billing responsibility for the entire package of care a resident receives during a covered Part A SNF stay.
SNF must submit Medicare claims for all services rendered to their residents under a covered Part A SNF stay, except for certain excluded/separately payable services
Refer to the CMS SNF Consolidated Billing external link page for the list of excluded/separately payable services
[CCYY] Part A MAC Update - Downloads
[CCYY] Part B MAC Update - Downloads
SNF must either furnish the service directly with their own resources or obtain the service from an outside entity (such as a supplier) under an “arrangement”
Under such arrangement, the SNF must reimburse the outside entity for those Medicare covered services subject to consolidated billing
Refer to the CMS Skilled Nursing Facility PPS Best Practices Guidelines external link for sample agreements if you need to establish payment arrangements with the SNF
Note: Absence of a valid arrangement does not invalidate the SNF’s responsibility to reimburse suppliers for services included in the SNF stay
Source(s): Centers for Medicare & Medicaid Services (CMS) internet-only manuals (IOM) 100-04, Chapter 6 external pdf file;
Chapter 1
external pdf file; MLN Matter Number MM4292 external pdf file ,
list item Please use your browser's back button to return to the referring page.
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