(Medicare Claims Processing Manual)

80.3 - Information Necessary to Permit Payment to a Facility  (Rev. 1, 10- 01-03) SNF -510.1  A facility may ordinarily qualify to receive Part B payment for the services of physicians in the facility by submitting a Form CMS -855R to its A/B MAC (A), certifying that it will bill for their services only as called for by its written contractual arrangements.   For purposes of Medicare benefits payable for the services, this agreement may be terminated by either party upon written notice to the other, but such termination is not binding upon Medicare until two weeks after the A/B MACs (A) receives a revised Form CMS -855R notice of this termination.  80.4 - Services Furnished Within the SNF  (Rev. 1, 10- 01-03) SNF -510.2  The term facility is limited for purposes of furnishing services to individuals as inpatients, e.g., hospitals, university medical centers that own and operate hospitals, SNFs, nursing homes, homes for the aged, or other institutions of a similar nature.  Physician services furnished outside the physical premises of the facility are considered furnished in the SNF if furnished in connection with services received by patients in the SNF.  For example, if SNF inpatients are taken to the private office of a neurologist for necessary tests such as an encephalograph, the services are considered performed in the SNF for billing and payment.  80.5 - Billing Under Arrangements  (Rev. 1, 10- 01-03) SNF -510.2  A provider may have others furnish certain covered items and services to their patients through arrangements under which receipt of payment by the provider for the services discharges the liability of the beneficiary or any other person to pay for the service.  In permitting providers to furnish services under arrangements, it is not intended that the provider merely serve as a billing mechanism for the other party.  Accordingly, for services provided under arrangements to be covered, the provider must exer cise professional responsibility over the arranged- for services.  See the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, Definitions, 10.3, for additional discussion on services furnished under arrangement.   The law is silent regarding specific terms of a SNFs payment to the outside provider or supplier and currently does not authorize the Medicare program to impose any requirements in this regard.  Thus, the issue of the outside provider or suppliers payment by the SNF is a private, contractual matter that must be resolved through direct negotiations between the parties.  However, services provided under consolidated billing arrangements must be provided by Medicare certified providers that are licensed to provide the service involved.  In addition, payment may not be made if the provider or supplier is subject to OIG sanctions that would prohibit Medicare payment for the service if the provider or supplier were billing independently.  In some cases, SNFs may purchase services for their patients from a hospital under arrangements.  Such services may include a physician component.  When the physician has entered into a valid contractual arrangement with the hospital in which his/her services are furnished for it to bill for the services, no additional written authorization is needed for SNFs to bill for his/her services.  For example, where SNFs arrange to obtain an EKG interpretation from Hospital B, and Hospital B has a valid contractual arrangement with its cardiologist authorizing it to bill for his/her services, SNFs do not need written authorization from the cardiologist to bill Medicare for the cost of the services.   See the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care (SNF) Services Under Hospital Insurance, 70.4, for additional information on services under arrangements.   80.6 - Indirect Contractual Arrangement  (Rev. 1, 10- 01-03) SNF -510.3  The necessary contractual arrangement between physicians and the facility in which they perform their services may exist indirectly by reason of the terms of their relationship with an employer and the employers contractual arrangement with the facility.  EXAMPLE   A professional corporation enters into a contractual arrangement with an SNF to provide physician services for it.  Under this arrangement, the SNF alone bills and receives payment for the physician services and pays the corporation a percentage of the cha rges.  The corporation, in turn, employs several physicians to provide the services, and under the terms of their employment, is entitled to any fees payable for the services (other than the portion of the fees retained by the SNF).  The combination of the  two arrangements -  between the SNF and the corporation and the corporation and the physicians -  constitutes an indirect contractual arrangement between the SNF and the physicians.  For the SNF to bill and receive payment for the physician services furnished in the SNF, the SNF must also enter into a direct contractual arrangement with the physicians for this purpose.   80.7 - Establishing That a SNF Qualifies to Receive Part B Payment on the Basis of Reassignment  (Rev. 1, 10-01-03) SNF -512  A SNF wishing to receive Part B payment as a reassignee of one or more physicians must furnish the A/B MAC (B) sufficient information to establish clearly that it qualifies or does not qualify to receive payment for their services.  Where there is any doubt that a SNF qualifies as a reassignee, A/B MACs (B) will obtain additional evidence.  In some cases, a SNF may qualify to receive payment for the services of a physician both as the employer of the physician and as the facility in which the services are performed.  As soon as it is determined that a SNF can qualify on either basis, no further development is undertaken with respect to that physician or to other physicians having the same status, and reassigned claims submitted by the SNF for services furnished by those physicians are honored.  However, where other physicians have, or appear to have different status, further development is required.  It is possible in some instances that a determination is made that Part B payment can be made only to the physician himself.  Where the SNF qualifies as a reassignee, it assumes the same liability for any overpayments that it may receive as a reassignee as the physician would have had if the payment had been made to him/her.  90 - Medicare Advantage (MA) Beneficiaries  (Rev. 1252, Issued:  05-25- 07; Effective:  10 -01-06; Implementation:  08 -27-07)  For billing to MA plans, SNFs follow the requirements of the agreement they have with the plans.  In cases where the patient may have enrolled or disenrolled from the plans during the billing period, the SNF will split the bill and send the plans portion to it and the remaining portion to the A/B MAC (A).  90.1 - Beneficiaries Disenrolled from MA Plans  (Rev. 1618, Issued: 10- 24-08, Effective: 04-01- 09; Implementation: 04 -06-09)  If a beneficiary voluntarily or involuntarily dis-enrolls from a risk MA plan while an inpatient of an SNF and converts to original Medicare (i.e., fee for service) the requirement for a three day hospital stay will be waived if  the beneficiary meets the level of care criteria found in 42 CFR 409, Subpart D, up through the effective date of dis-enrollment.  The beneficiary will then be eligible for the number of days that remain out of the 100 day SNF benefit for that particular SNF stay minus those days that would have been covered by the program under original Medicare while the beneficiary was enrolled in the risk MA plan.  However, in cases where the beneficiary disenrolls from a risk MA plan after discharge from the SNF, and then is readmitted to the SNF under the 30 day rule, all requirements for original Medicare (i.e., fee for service), including the 3-day hospital stay must be met.  Rules regarding cost sharing apply to these cases.  That is, providers may only charge beneficiaries for SNF coinsurance amounts.  If the beneficiary voluntarily disenrolls from a risk MA plan and converts to original Medicare (i.e., fee for service) before admission to a SNF then the beneficiary must meet all original Medicare requirements for a SNF stay, including that of a three day inpatient hospital stay.  SNFs submit all applicable fee -for-service inpatient SNF claims with condition code 58 to indicate a patient was disenrolled from an MA plan and the 3-day prior stay requirement was not met.  Claims with condition code 58 will not require the 3-day prior inpatient hospital stay.  The A/B MAC (A) must use CWF files to validate the beneficiary was enrolled in an MA organization upon admission to the SNF and that the MA enrollment period ended prior to the from date on the claim.  The A/B MAC (A) does not need to verify that the MA plan was the one that terminated.   90.2 - Medicare Billing Requirements for Beneficiaries Enrolled in MA Plans  (Rev.4491, Issued: 01- 09- 20, Effective: 04-01-20, Implementation: 04-06-20)  If a beneficiary chooses an MA plan as his or her form of Medicare, he/she cannot look to traditional fee for service Medicare to pay the claim if the MA plan denies coverage.  SNF providers shall apply the following policies to MA beneficiaries who are admitted to a SNF:   If the SNF is non-participating with the plan, the beneficiary must be notified of his or her status because he/she MAY be private pay in this circumstance, depending upon the type of MA plan in which he/she is enrolled;    If the SNF is participating with the plan, pre-approve the SNF stay with the plan;    If the plan denies coverage, appeal to the plan, not to the fee for service FI;    Count the number of days paid by the plan as Part A days used (this IS the beneficiarys 100 days of Medicare SNF benefits);    Submit a claim to the fee for service A/B MAC (A) to subtract benefit days from the CWF records. (Note: The plans do not send claims to CWF for SNF stays). Failure to send a claim to the A/B MAC (A) will inaccurately show days available.    If a beneficiary no longer requires skilled care under the MA plan the SNF may discharge the patient using a patient status code 04. No- payment bills are not required for beneficiaries that are receiving non-skilled care and are enrolled in an MA plan. If the beneficiary again requires skilled care after a period of non-skilled care, the provider should begin a new admission claim for Medicare to continue the spell of illness.   Billing Requirements   Submit covered claims and include a HIPPS code (use default code AAA00 prior to 10/1/2019 and ZZZZZ after 10/1/2019) if no assessment was done), room and board charges and condition code 04.   NOTE: If the beneficiary drops his or her MA plan participation during their SNF stay, the beneficiary is entitled to coverage under Medicare FFS for the number of days available that remain out of the 100 days available under the SNF benefit.    100 - Part A SNF PPS for Hospital Swing Bed Facilities  (Rev. 1, 10-01-03) PM A -02-016  Section 4432(a) of the Balanced Budget Act (BBA) of 1997 specifies that swing bed facilities must be incorporated into Part A SNF PPS by the end of the statutory transition period.  Effective with cost reporting periods beginning on or after July 1, 2002, swing bed bills are not paid on the cost-based method, but rather on the basis of the Part A SNF PPS.  These payment rates cover all payment for furnishing covered swing bed extended care services (routine, ancillary, and capital -related costs) other than approved educational activities as defined in 42 CFR 413.85.  Part A SNF PPS applies to short-term hospitals, long-term care hospitals, and rehabilitation hospitals that have Medicare swing bed agreements.  CAHs with swing beds are exempt from the Part A SNF PPS, and are not affected by these instructions.  The Part A PPS is phased in based on each swing bed hospitals fiscal year.  The transition to Part A PPS is effective with the start of the providers first cost reporting period that begins on or after July 1, 2002.  Consequently, billing for all benefic iaries in a swing bed must be split at the end of the providers fiscal year.  A new bill is created for beneficiaries remaining in the facility at the start of the new fiscal year.  The bill must be prepared under the Part A PPS claim guidelines described  in this chapter and in Chapter 1, General Billing Requirements.  Payment is made according to the instructions for SNFs under Part A PPS found in the Medicare Provider Reimbursement Manual.