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Last Modified: 5/10/2019 Location: FL, PR, USVI Business: Part A

Claims overlap FAQs

Q: The claim for my patient’s dates of service overlaps a Medicare Advantage (MA) plan and hospice elections period. Should I bill the hospice, traditional Medicare, or the MA plan?
A: Federal regulations require that Medicare administrative contractors (MAC) maintain payment responsibility for managed care enrollees who elect hospice.
While a hospice election is in effect, certain types of claims may be submitted to the MAC, by either the hospice provider or a provider treating an illness not related to the terminal condition. These claims are subject to the usual Medicare rules of payment, but only for the following services:
Hospice services covered under the Medicare hospice benefit are billed by the Medicare hospice
Institutional providers may submit claims to Medicare with the condition code “07” when services provided are not related to the treatment of the terminal condition
MA plan enrollees that elect hospice may revoke hospice election at any time, but claims will continue to be paid by the MAC as if the beneficiary were enrolled in Medicare until the first day of the month following when hospice election was revoked
Example:
Beneficiary’s hospice election period ended on 1/10/YY
Bill the MAC for claims for dates of service 1/11/YY to 1/31/YY
Bill the MA plan for claims for dates of service 2/1/YY and beyond
Refer to resolution tips for overlapping claims, the A/B Medicare administrator contractor (MAC) collaborative job aid on how to resolve and prevent overlapping claim situations.
Source: CMS internet-only-manual, publication 100-04, Chapter 11 external pdf file, section 30.4, 50
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