(Medicare Claims Processing Manual)

Payment sanctions are applied to days that would otherwise be Part A-payable; i.e., the care is covered but no payment will be made to the provider. Therefore, if the Medicare participating SNF assumes responsibility for the beneficiarys costs during the sanction period, it will be considered the same as a program payment, and the days will count towards the 100-day benefit period.  In situations where the beneficiary is subject to the payment ban, but the provider fails to issue the proper beneficiary liability notice, the provider is liable for all services normally covered under the Medicare Part A benefit.  Since the beneficiary i s receiving benefits, the days will be considered Part A days and charged against the beneficiarys benefit period.  The SNF may collect any applicable copayment amounts.  These days will be charged against the beneficiarys utilization as is currently done with other types of technical denials (i.e., late filing, late denial notices to the patient, etc.).   If the SNF issues the appropriate beneficiary liability notice, and the beneficiary agrees to make payment either personally or through a private insurer, the days will not be charged towards the 100-day benefit period.  50.2 - Billing When Ban on Payment Is In Effect  (Rev. 1555; Issued:  07- 18-08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)  Beneficiaries admitted before the effective date of the denial of payment and taking temporary leave, whether to receive inpatient hospital care, outpatient services or as therapeutic leave, are not considered new admissions, and are not subject to the denial of payment upon return. This policy applies even if there are multiple hospitalizations and returns to the SNF during the period sanctions are in effect.  When determining if the beneficiary was admitted prior to the imposition of the ban, the actual status of the beneficiary rather than the primary payor is the determining factor.  Therefore, there may be situations where the beneficiary is a private pay patient or a dual eligible who was receiving Medicaid benefits prior to the imposition of the payment ban.  If this private pay patient or dual eligible goes to the hospital for need ed care, and meets the Medicare Part A criteria for SNF coverage upon return to the SNF, the readmission is exempt from the denial of payment sanction.  When billing for a readmission that is NOT subject to the payment ban, providers must enter occurrence span code 80, Prior Same -SNF Stay Dates for Payment Ban Purposes, on the claim to identify the prior same -SNF stay dates, in addition to reporting any LOA and prior hospital stay dates, using occurrence span codes, that may affect the A/B MACs (A)s determ ination of payment ban exemption status.  See Chapter 25 of this manual for occurrence span code titles and definitions.  50.2.1 - Effect of an Appeal to a DPNA on Billing During the Period the SNF is Subject to a DPNA (Rev. 1555; Issued:  07- 18-08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)  In those situations where the SNF decides to appeal the imposition of a DPNA, it must still bill the program as set forth in the instructions below.   50.2.2 - Provider Liability Billing Instructions  (Rev. 1555; Issued:  07- 18-08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)  The SNF must file a covered bill with the A/B MAC (A) using occurrence span code 77 that indicates the facility is liable for the services in situations where the SNF failed to issue the proper beneficiary liability notice and any applicable copayments wil l be charged to the beneficiarys Part A benefit period.  Furthermore, the sum of all covered units reported on all revenue code 0022 lines should be equal to the covered days field less the number of provider liable days reported in the occurrence span code 77.  See 60 of Chapter 1 in this manual for detailed instructions on nonpayment billing requirements.   When the SNF is liable for the Part A stay, the SNF is required to provide all necessary covered Part A services, including those services such as therapies and radiology mandated under consolidated billing.  For example, if the beneficiary goes to the hos pital for a non- emergency chest x -ray, the SNF will be responsible for the outpatient hospital radiology and any ambulance charges.  In this case, the SNF may not charge the beneficiary or family members for any services that, in the absence of a payment sanctio n, would have been covered under the Part A PPS payment.  50.2.3 - Beneficiary Liability Billing Instructions  (Rev. 1555; Issued:  07-18- 08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)   The SNF shall file a non -payment bill for noncovered Part A services, using condition code 21 that indicates beneficiary liability.  Services that would have been eligible for Part A benefits in the absence of sanctions cannot be billed as Part B charges.  However, the SNF may directly bill the beneficiary, family members or other third party insurers for services provided to that beneficiary.  50.2.4 - Part B Billing (Rev. 1, 10-01-03)  PM AB -01-131  Facilities subject to a payment ban may continue to bill services for beneficiaries who are not in a Part A stay in the same way as any other SNF.  However, services that would have been payable to the SNF as Part A benefits in the absence of a payment sanction must not be billed to either the A/B MAC (A) or the A/B MAC (B) as Part B services.   50.3 - Sanctions Lifted: Procedures for Beneficiaries Admitted During the Sanction Period  (Rev. 1, 10-01-03)  PM AB -01-131  For new admissions to certified beds, Medicare payments for eligible beneficiaries should begin on the date the sanction is lifted.  The beneficiary must meet technical eligibility requirements (e.g., a 3- day hospital stay, etc.), services must be reasonable and necessary and the beneficiary must be receiving skilled care.  The date the sanction is lifted is considered the first day of the Part A stay.  For Part A PPS payment purposes, the period between the actual date of admission and the last day the sanction was in effect should be billed as noncovered days.  (See 50.3.1 below on procedures to track these noncovered days for benefit period and break in spell of illness calculations.  RAI requirements are discussed in 30.5.)  50.3.1 - Tracking the Benefit Period  (Rev. 1555; Issued:  07-18- 08; Effective Date:  01 -01-09; Implementation Date: 01-05-09)   SNF days during the sanction period will be used to track breaks in the spell of illness if a beneficiarys care in the SNF meets the skilled level of care requirements.  If the patient is receiving a skilled level of care the benefit period cannot end.  T herefore, it will be tracked in CWF.   50.3.2 - Determining Whether Transfer Requirements Have Been Met  (Rev. 1, 10- 01-03)  PM AB -01-131  It is very important to safeguard the beneficiary while applying necessary sanctions to the provider.  It is certainly possible that a beneficiary may remain at a facility under sanction for a period of time and later transfer to a second SNF.  The 30- day transfer requirement will be applied in the same way it would be for a beneficiary transferring between two SNFs that are not under sanction.  Part A coverage will be available to the second SNF for all remaining days in the benefit period as long as the beneficiary:   1. Had a qualifying hospital stay  2. Was admitted to a Medicare -certified bed in the first (sanctioned) SNF within 30 days of the hospital discharge, and   3. Is receiving a covered level of care at the time of transfer.   50.4 - Conducting Resident Assessments  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  The imposition of sanctions does not waive the SNFs responsibility to perform assessments in accordance with the clinical schedule defined in the SOM.  Comprehensive admission assessments are still due within 14 days of admission to the SNF. Facility staf f must also maintain the schedule for quarterly and annual assessments, and perform SCSAs and SCPAs when clinically appropriate.   Medicare- required assessments are also necessary for all beneficiaries in the SNF whose stays are not subject to the payment ban.  If, during the sanction period, staff do not perform Medicare- required assessments for beneficiaries in covered Part A stays,  no payment is made and the SNF must submit a claim using the HIPPS default rate code and an occurrence code 77 indicating provider liability, in order to ensure that the beneficiarys spell of illness (benefit period) is updated.   Part A benefits are NOT available for beneficiaries admitted after the effective date of the payment ban.  Therefore, the facility is not required to perform Medicare PPS assessments.  Medicare payments can begin no earlier than the date the sanction is li fted.  For Medicare PPS assessment scheduling purposes, the date the sanction is lifted should be considered day 1.  In this case, if the sanctions are lifted effective June 15, the assessment reference date for the Medicare 5 -day assessment must be set between June 15 and June 22 (i.e., the eighth day of the covered stay).  An SNF may choose to perform the Medicare -required assessments during the sanction period, but is not required to do so.  Generally, a facility should continue to do the Medicare PPS assessments if SNF staff believe the sanction was in error and may be lifted retroactively.  In this case, the SNF would be able to bill Medicare at the correct rate.  When the SNF does not receive timely notification that a payment ban has been lifted, and staff is unaware of the need to start the Medicare- Required schedule (the beneficiary meets all applicable eligibility and coverage requirements), the SNF shall bill the Medicare 5 -day and 14- day assessment using the HIPPS code generated by the 14- day OBRA required assessment.  If the SNF did not perform any assessments with an assessment reference date during the assessment window for the Medicare -Required 5-day or 14- day assessment, the SNF shall bill the default rate for those covered days associated with the assessment.  Where the SNF did not perform an assessment with an ARD that fell in the applicable Medicare -Required Assessment window for the 30, 60 and 90- day M edicare- Required Assessments it shall bill the default rate.  If the SNF did perform an assessment, including a SCSA, where the ARD fell in the window of a 30, 60 or 90- day Medicare- Required Assessment (including grace days), the SNF shall bill using the H IPPS code generated from the assessment in accordance with the payment policies found in Chapter 28 of the Provider Reimbursement Manual.  The date the sanction is lifted is Day 1 for purposes of the Medicare assessment schedule.   NOTE : In order to bill with the default code the beneficiary must at least meet the requirements for SNF coverage.   EXAMPLE 1 : The SNF is notified on June 15th that its payment ban was lifted effective June 1.  The beneficiary was admitted on June 1.  The SNF did not perform any of the Medicare -Required Assessments.  However, the SNF did perform the initial OBRA assessment.  The initial OBRA assessment shall be used to bill the 5- day Medicare -Required Assessment for up to 14 days.  Day 15 is day 1 for purposes of starting the Medicare -required assessment schedule and a 5 -day Medicare required assessment shall be performed.   EXAMPLE 2:  The SNF is notified on August 15 that its payment ban was lifted on June 1.  The beneficiary was admitted on June 1.  The SNF did not perform any of the Medicare -Required Assessments.  However, the SNF did perform the initial OBRA Assessment.  The initial OBRA assessment shall be used to bill the 5 -day Medicare required assessment and the 14 -day Medicare required assessment.  The 30 -day assessment shall be billed through day 44 at the default rate.  Day 45 is day 1 for purposes of starting the Me dicare - required assessment schedule and a 5 -day Medicare required assessment shall be performed.   See 120.1 for the revised Medicare -required assessment schedule under the SNF PDPM effective October 1, 2019.  50.5 - Physician Certification  (Rev. 1, 10- 01-03)  PM AB -01-131  The SNFs under a payment ban are still participating providers, and remain subject to Medicare coverage requirements.  Providers are still responsible for evaluating whether beneficiaries meet the Medicare Part A medical necessity and level of care requirements for Medicare Part A coverage, and for obtaining the required physician certifications even though Medicare payment cannot be made for the admission.  The SNFs are required to obtain physician certifications upon notification that a sanction was lifted.  The date of notification will be considered day 1 when verifying the timeliness of the physician certification.