(Medicare Claims Processing Manual)

Any nonutilization days after the beneficiary exhausts coinsurance or LTR days before the OC 47 date will be identified using OSC 70.  LTR days should be used as necessary and as elected by the beneficiary.  If coinsurance days are exhausted during the inl ier portion of the stay and there is a period of nonutilization indicated by the presence of OSC 70 and the beneficiary elects not to use LTR days, covered charges are limited to the exact amount of the cost outlier threshold and both OC A3, which shows the last covered day, and OC 47, which shows the following day which is the first full day of cost outlier status, must be shown.  When coinsurance and/or LTR days are exhausted during the cost outlier portion of the stay, OC A3 should be used as appropriate  to report the date benefits are exhausted.  Covered charges should be accrued to reflect the entire period of the bill if the bill is fully covered or the entire period up to and including the date benefits were exhausted, if benefits were exhausted.   Assumptions for all of the following examples:   1. Cost outlier threshold amount is $50,000.  2. Threshold amount is reached on the 25th day.   3. Billed charges are $1,000 each day thereafter.   4. Beneficiary elects to use any available LTR days.   EXAMPLE 1: LTR Days Cover Cost Outlier   Date of Service:  1/1 - 1/31 discharge  Medically necessary days  30 Covered charges  $55,000  Benefits available  30 LTR  Covered days  30 Noncovered days  0 Cost report days  30 All charges for Medicare approved revenue codes billed as covered  No OC 47 needed   Reimbursement:  Full DRG plus cost outlier based on $55,000 covered charges   EXAMPLE 2:  LTR Days Exhaust in the Cost Outlier   Dates of service:  1/1 - 2/10 discharge  Medically necessary days:  40 Covered charges:  $65,000  Benefits available:  30 LTR  Covered days:  30 Noncovered days:  10 Cost report days:  30 30 days covered charges for Medicare approved revenue codes and 10 days noncovered charges.  OC 47:  1/26 OC A3:  1/30 Reimbursement:  Full DRG plus cost outlier based on $55,000 covered charges ($50,000 inlier and $5,000 outlier   EXAMPLE 3:  LTR Days Exhaust Prior to Cost Outlier   Dates of service:  1/1 - 1/31 discharge  Medically necessary days:  30 Covered charges:  $55,000  Benefits available:  20 LTR  Covered days:  20 Noncovered days:  10 Cost report days:  25 25 days covered charges for Medicare approved revenue codes and 5 days noncovered charges  OC 47:  1/26 OC A3  1/25 OSC 70:  1/21 -1/25 Reimbursement:  Full DRG payment, no cost outlier   EXAMPLE 4:  Coinsurance Days Exhaust Prior to Cost Outlier and No LTR Days Are Available   Date of Service:  1/1 - 1/31 discharge  Medically necessary days  30 Covered charges  $55,000  Benefits available:  20 coinsurance  Covered days:  20 Noncovered days:  10 Cost report days:  25 25 days covered charges for Medicare approved revenue codes and 5 days noncovered charges  OC 47:  1/26 OC A3:  1/25 OSC 70:  1/21 - 1/25  Reimbursement:  Full DRG payment, no cost outlier   EXAMPLE 5: Coinsurance Days Exhaust Prior to Cost Outlier.  LTR Days Exhausts in the Cost Outlier   Date of Service:  1/1 - 2/10 discharge  Medically necessary days  40 Covered charges  $65,000  Benefits available:  20 coinsurance and 10 LTR  Covered days:  30 Noncovered days:  10 Cost report days:  35 35 days covered charges for Medicare approved revenue codes and 5 days noncovered charges  OC 47:  1/26 OC A3:  2/4 OSC 70:  1/21 - 1/25  Reimbursement:  Full DRG payment, plus cost outlier based on $60,000 covered charges ($50,000 inlier, $10,000 outlier, $5,000 noncovered)   EXAMPLE 6: Full and Coinsurance Days Cover Cost Outlier   Date of Service:  1/1 - 1/31 discharge  Medically necessary days  30 Covered charges  $55,000  Benefits available:  10 full and 20 coinsurance  Covered days:  30 Noncovered days:  0 Cost report days:  30 All charges for Medicare approved revenue codes billed as covered.  OC 47:  Not needed  Reimbursement:  Full DRG payment plus cost outlier based on $55,000 covered charges.   EXAMPLE 7: Coinsurance Days and LTR Days Exhaust in the Cost Outlier   Date of Service:  1/1 - 2/28 discharge  Medically necessary days  58 Covered charges  $83,000  Benefits available:  10 full, 30 coinsurance and 10 LTR  Covered days:  50 Noncovered days:  8 Cost report days:  50 50 days covered charges for Medicare approved revenue codes and 8 days noncovered charges  OC 47:  1/26 OC A3:  2/19 Reimbursement:  Full DRG payment, plus cost outlier based on $75,000 covered charges ($50,000 inlier, $25,000 outlier, $8,000 noncovered)   EXAMPLE: 8: LTR Days Exhaust Prior to Cost Outlier and Noncovered Span(s) Present   Dates of service:  1/1 - 1/31 discharge  Medically necessary days:  28 OSC 76  1/10 - 1/11 Covered charges:  $55,000  Benefits available:  20 LTR  Covered days:  20 Noncovered days:  10 Cost report days:  25 25 days covered charges for Medicare approved revenue codes and 5 days noncovered charges  OC 47:  1/28 OC A3  1/27 OSC 70:  1/23 -1/27 Reimbursement:  Full DRG payment, no cost outlier   20.8 - Payment to Hospitals and Units Excluded from IPPS for Direct Graduate Medical Education (DGME) and Nursing and Allied Health (N&AH) Education for Medicare Advantage (MA) Enrollees  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04 -07-08)  During the period January 1, 1998 through December 31, 1998, hospitals received 20 percent of the fee -for-service DGME and operating IME payment. This amount increased by 20 percentage points each consecutive year until it reached 100 percent in calendar year (CY) 2002.  Non-IPPS hospitals and units may submit their MA claims to their respective A/B MACs (A) to be processed as no -pay bills so that the MA inpatient days can be accumulated on the Provider Statistics & Reimbursement Report (PS&R) (report type 118) for DGME pa yment purposes through the cost report.   This applies to the following hospitals and units excluded from the IPPS:    Rehabilitation units    Psychiatric units    Rehabilitation hospitals    Psychiatric hospitals    Long- term Care hospitals    Childrens hospitals    Cancer hospitals   In addition, this applies to all hospitals that operate a nursing or an allied health (N&AH) program and qualify for additional payments related to their MA enrollees under 42 CFR 413.87(e).  These providers may similarly submit their MA claims to their r espective A/B MACs (A) to be processed as no -pay bills so that the MA inpatient days can be accumulated on the PS&R (report type 118) for purposes of calculating the MA N&AH payment through the cost report.   Non-IPPS hospitals, hospitals with rehabilitation and psychiatric units, and hospitals that operate an approved N&AH program must submit claims to their regular A/B MAC (A) with condition codes 04 and 69.  The provider uses Condition code 69 to indicate that the claim is being submitted as a no -pay bill to the PS&R report type 118 for MA enrollees in non- IPPS hospitals and non- IPPS units to capture MA inpatient days for purposes of calculating the DGME and/or N&AH payment through the cost report.   The A/B MAC (A) submits the claim to the Common Working File (CWF).  The CWF determines if the beneficiary is a MA enrollee and what his/her plan number and effective dates are.  The plan must be a MA plan, per 42 CFR 422.4.  Upon verification from CWF that the beneficiary is a MA enrollee, the A/B MAC (A) adds the MA plan number and an MA Pay Code of 0 to the claim.  For fee -for-service claims that were previously paid and posted to history for the same period (due to late posting of MA enrollment data) , an L -1002 Automatic Cancellation Adjustment Report will be sent to the A/B MAC (A) when a DGME -only or a N&AH- only claim from a non- IPPS hospital or unit is accepted for payment by CWF. No deductible or coinsurance is to be applied against this claim nor  is the beneficiary's utilization updated by CWF for this stay.  If CWF enrollment records do not indicate that the beneficiary is a MA enrollee, CWF rejects the claim and the A/B MAC (A) notifies the hospital of this reason.  The hospital may resubmit the claim after 30 days to see if the enrollment data has been updat ed. No interim bills should be submitted for DGME -only or N&AH -only claims and no Medicare Summary Notices should be prepared for these claims.  The DGME payments are made using the same interim payment calculation A/B MACs (A) currently employ.  Specifically, A/B MACs (A) must calculate the additional DGME payments using the inpatient days attributable to MA enrollees.  As with DGME and N&AH educa tion payments made under fee -for-service, the sum of these interim payment amounts is subject to adjustment upon settlement of the cost report.  Note that these DGME and/or N&AH payments apply both to IPPS and non- IPPS hospitals and units.   Teaching hospitals that operate GME programs (see 42 CFR 413.86) and/or hospitals that operate approved N&AH education programs (see 42 CFR 413.87) must submit separate bills for payment for MA enrollees.  The MA inpatient days are recorded on PS&R repor t type 118. For services provided to MA enrollees by hospitals that do not have a contract with the enrollees plan, non- IPPS hospitals and units are entitled to any applicable DGME and/or N&AH payments under these provisions.  Therefore, such hospitals and units should submit bills to their A/B MAC (A) for these cases in accordance with this sections instructions.  In addition to submitting the claims to the PS&R report type 118, hospitals must properly report MA inpatient days on the Medicare cost report , Form 2552- 96, on worksheet S -3, Part I, line 2 column 4, and worksheet E -3, Part IV, lines 6.02 and 6.06.  30 - Medicare Rural Hospital Flexibility Program and Critical Access Hospitals (CAHs)  (Rev. 68, 10- 16-04)  A3-3610.19, HO -415.19, A3- 3610.20, HO -415.20  The Medicare law allows establishment of a Medicare rural hospital flexibility program by any State that has submitted the necessary assurances and complies with the statutory requirements for designation of hospitals as critical access hospitals (CAHs).