(Medicare Claims Processing Manual)

SNF inpatient adjustment requests adhere to the same billing instructions as non- inpatient adjustment requests with the following changes.  When an initial bill has been submitted and the provider or FI discovers an error on the bill, an adjustment request  is submitted if the change involves one of the following:    A change in the Part B cash deductible of more than $1.00  A change in the number of inpatient days;   A change in the blood deductible;   A change in provider number;   A change in coinsurance which involves an amount greater than $1.99;   A change in the HIPPS code to correct a data input error or,   Effective for changes for services June 1, 2000, change in HIPPS code due to an MDS correction.  (Such adjustments are required within 120 days of the through date on the initial bill.) NOTE:  See Chapter 6, Section 35 for information on submitting adjustments to HIPPS codes resulting from MDS corrections.  Late charge billings (type of bill xx5) are not acceptable for SNF PPS Part A services.  The reason for an adjustment (Claim Change Reasons) is reported in one of the condition code fields.  Claim Change Reason Codes applicable to SNFs are:   D0 Changes to Service Dates  D6 Cancel only to repay a duplicate OIG payment  D1 Changes to Charges  D7 Change to Make Medicare Secondary Payer  D2 Changes in Revenue codes/ HCPCS - HIPPS  D8 Change to Make Medicare Primary Payer  D4 Changes in Grouper code  D9 Any Other Change  D5 Cancel to correct Medicare beneficiary identifier or Provider ID  E0 Change in Patient Status   The SNF selects the one code that best describes the change reason.  An adjustment may contain multiple changes even though only one reason code is reported.    130.3.2 - SNF Inpatient Claim Adjustment Instructions  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  1. Type of Bill is 217, (replacement bill).   2. Internal Control Number (ICN)/Document Control Number (DCN) Required.  All providers requesting an adjustment to a previously processed claim must insert the ICN/DCN of the claim to be adjusted.  Payer As ICN/DCN must be shown on line A.  Similarly, the ICN/DCN for Payers B and C must be shown on lines B and C respectively.   3. Appropriate Claim Change Reason Code.   4. The provider must submit an entire replacement debit.  Note:  Information regarding the form locator numbers that correspond to these data element names and a table to crosswalk UB -04 form locators to the 837 transaction is found in Chapter 25.   130.3.3 - Patient Does Not Return From  SNF Leave of Absence, and Last Bill Reported Patient Status as Still Patient (30)  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  Where the patient does not return from a leave of absence, regardless of the reason, the SNF must submit a discharge bill showing the date of discharge as the date the individual actually left.  If the patient status was reported as 30 (still patient) on  an interim bill and the patient failed to return from a leave of absence within 30 days, including the day leave began, or has been admitted to another institution at any time during the leave of absence, the SNF must submit an adjustment request to corre ctly indicate the day the patient left as the date of discharge.  (A beneficiary cannot be an inpatient in two institutions at the same time.)  This closes the open admission on the patients utilization record.   NOTE: Home health or outpatient services provided during a leave of absence do not affect the leave and no discharge bill is required.   EXAMPLE l:   The beneficiary goes on a leave of absence on January 3, expecting to return on January 10.  On January 6, the SNF receives word that the patient died on January 5.  The SNF submits a discharge bill showing January 3 as the date of discharge.   EXAMPLE 2:   The beneficiary goes on a leave of absence on February 6, expecting to return on February 12.  However, the beneficiary does not return on February 12 as expected and the SNF cannot determine whether the beneficiary will return.  The SNF submits a discharg e bill showing February 6 as the date of discharge as soon as practical, or after 30 days have elapsed from the day the leave began.  If an interim bill had been submitted showing the beneficiary in still patient status as of February 6 or later, the SNF  submits an adjustment request showing February 6 as the discharge date.  The advantage of delaying the discharge bill for 30 days is that it will make unnecessary a new admission notice in the event the beneficiary returns before 30 days have elapsed.   EXAMPLE 3:   The beneficiary goes on a leave of absence on March 4, and is expecting to return April 1 but does not.  The SNF submits a discharge bill showing March 4 as the date of discharge since the beneficiary did not return within the 30- day period.   130.4 - Hospital and SNF Part B Adjustment Requests  (Rev. 1, 10- 01-03) 130.4.1 - Guidelines for Submitting Adjustment Requests  (Rev. 1, 10- 01-03) SNF -562, SNF -562.A  When an initial bill for outpatient services or inpatient Part B services has been submitted and the provider or the FI discovers an error, the provider submits an adjustment request to the FI.  The FI submits the adjustment to CMS if there is a change in:   The Part B cash deductible of more than $1;   Covered charges of more than $1 on bills for surgery or other outpatient procedures;   The servicing provider;   The Part B blood deductible;   The coinsurance amount greater than $1.99; or   Procedure codes.  130.5 - Home Health Adjustments  (Rev. 1, 10- 01-03)  130.5.1 - Submitting Adjustment Requests  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   A home health agency submits a corrected Form CMS -1450 if any of the following apply:   A change in provider number;   A change in coinsurance involves an amount greater than $1.99; or   A change in visits (decrease or increase).  Where there are money adjustments other than a coinsurance amount greater than $1.99, the agency records the difference on a record sufficiently documented to establish an accounting data trail, including patients name and Medicare beneficiary identifier, first  and last dates of services, and any unique numbering or filing code necessary to associate the adjustment charge with the original billing.  A number of conditions can cause the episode payment to be adjusted.  Both RAPs and claims may be cancelled by HHAs if a mistake is made in billing (TOB 328), though episodes will be cancelled in CWF as well.  Adjustment claims may also be used to change i nformation on a previously submitted claim (TOB 327), which may also change payment.  RAPs can only be cancelled, not adjusted, but may be re -billed after cancellation.   130.6 - Adjustments to Reprocess Certain Claims Denied Due to an Open Common Working File (CWF) Medicare Secondary Payer (MSP) Group Health Plan (GHP) Record Where the GHP Record Was Subsequently Deleted or Terminated  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Group Health Plan (GHP) Medicare Secondary Payer claims were not reprocessed automatically in situations where Medicare becomes the primary payer after an MSP GHP record was deleted, or when an MSP GHP record was terminated, after claims were processed subject to the CWF record. It was the responsibility of the beneficiary, provider, physician or other supplier to contact the Medicare contractor and request the denied claims be reopened when reopening was permitted. This was a burden on the beneficiary, physician, or other supplier. This instruction directs CWF to implement an automated process to reopen certain MSP claims when MSP GHP records were 1) deleted, or 2) under some circumstances, certain MSP GHP records were terminated and claims were denied (rej ected for Part A claims) due to MSP or Medicare made a secondary payment before the termination date was accreted.   The COBC currently identifies, deletes, and terminates MSP GHP records on the CWF when appropriate.  The 1 -800 Medicare also applies simple terminations to MSP GHP working aged records only. Upon deletion of an MSP record, or where a termination dated added to an MSP GHP (MSP Codes 12, 13, 43) record, this instruction directs the CWF to search the claims history for claims, with dates of service within 180 days of the deletion date, or the dat e the termination date was applied, which were processed for secondary payment or were denied because of the MSP edit  as set forth in 42 CFR 405, subpart G, H and I. The Shared Systems shall reopen these claims, as necessary, including locating any claims billed to Medicare as primary, or secondary, and denied (rejected for Part A claims) on the basis of the subsequently deleted CWF MSP GHP record. Claims with added termination dates shall be reopened no earlier than the termination date applied to CWF.   The CWF shall generate an unsolicited response W and send this response with the 24 and 10 trailers containing the identifying information regarding any such claims found to the shared system.  The unsolicited response shall include all the necessary inf ormation to identify the claim(s), including the Document Control Number/Internal Control Number/Claim Control number, Medicare beneficiary identifier , beneficiary name, and date(s) of service.  The CWF electronically transmits this unsolicited response to the claims processing contractor(s) that originally processed the claim(s) or send the claim to the MAC contractor that assumed the workload for the original legacy contractor that processed the claim. The previously denied claim(s) (rejected for Part A) is not to be canceled and remains on the CWF claims history pending subsequent adjustment as warranted.   Upon receipt of the unsolicited response, the shared system software reads the claim information in the trailer for each claim and performs an automated reopening to each claim.  The claim(s) must be reopened and adjusted as warranted for all non -reimburse d/claim denials (part A rejections)/ where Medicare paid secondary or terminations that were based upon the MSP GHP record that was just deleted or terminated. The MSP unsolicited responses are reported with the current MSP responses when COB deletes an MS P record a 03 will be received. The shared systems release the adjusted claims. Adjustments are subject to all applicable edits as the original claim(s) and sent to the CWF so that the claim(s) on the CWF history are replaced with the adjusted claim(s) r ecords.   The automated MSP GHP reprocessing requirement allows CWF to alert the shared system when a MSP GHP record is deleted or a termination date added for specific beneficiaries. The shared systems and Medicare Contractors receive an IUR transaction response fr om CWF alerting the system to reprocess certain MSP GHP claims where the open GHP record was deleted /terminated by the Coordination of Benefits Contractor (COBC) or 1 -800-Medicare.  This unsolicited transaction is sent to the contractors on record at CWF who had claim history for the associated beneficiary within the 180 day period.  The CWF system is already programmed to send an updated MSP transaction (HUSC transaction) any time a change is made to an MSP record and this process does not change.       130.7 - MAC Guidance Related to Use of Adjustment Codes on Adjustment Claims (Rev. 4415; Issued: 10- 11-19; Effective: 01 -01-20; Implementation: 01 -06-20)