Claims

Published 07/15/2022

An overlap is when an incorrect claim submitted by the same or a different provider is processed and posted to the common working file (CWF), resulting in claim overlap rejection(s) of subsequent claim(s). When more than one provider is involved, the providers must work together to resolve the error. Some overlapping claim examples include:

  • Same provider — dates of service overlap
  • Charges that should have been combined on one claim
  • Outpatient claim submitted before allowing time for inpatient claim(s) to finalize
  • Claims that should have been submitted in service date sequence
  • Different provider — dates of service overlap
  • Did not report a leave of absence on the claim
  • Services subject to consolidated billing
  • Incorrect patient status code was submitted

Last Reviewed: 07/15/2022

The facility with the claim for the earliest dates of service may have billed an incorrect patient discharge status code. Applying the correct patient status code will help assure that the facilities receive prompt and correct payment.

  • If your patient status code is incorrect, it can indicate a patient is still in your facility when, in fact, they were discharged and admitted to another facility. It is recommended that you submit an adjustment to update the patient status on your claim.
  • If the other facility has submitted an incorrect patient status code, it is recommended that you contact the other facility and ask them to update the patient status code on the claim

Example
The claim indicates that the patient is still in your facility (patient status 30), but the patient was transferred to a Medicare certified skilled nursing facility (SNF) (patient status 03).

Resource: CMS internet-only-manual (IOM), 100-04, Chapter 25 (PDF) 

Last Reviewed: 07/15/2022

If you receive an overlap reason code, you can do one of the following:

  • Verify your claims submitted through direct data entry (DDE)
    • Option -1 (Inquiry Menu), then option -12 (Claims Summary), and key in the Medicare beneficiary identifier (MBI), your provider number, and press Enter
    • Review the list of claims submitted to identify those with identical dates of service, and validate they were submitted accurately
    • Verify eligibility for home health episodes and hospice election from ELGA and/or ELGH screens
  • Verify the Beneficiary/Eligibility tab submenu on the eServices secure provider online tool
    • Home health episode "start" and "end" date, and the servicing provider’s NPI
    • Hospice election effective and termination date, revocation code and the servicing provider’s NPI
    • NPI registry lookup enables you to search for the provider’s information
  • Verify additional eligibility information from the submenu on the interactive voice response (IVR)
    • Hospice effective and termination dates (if applicable), and the servicing provider’s ID
    • Home health effective and termination dates (if applicable), and the servicing provider’s ID
    • SNF effective and termination dates (if applicable), and the servicing provider’s ID 

Last Reviewed: 07/15/202

While providers/facilities are required and expected to work together to resolve a billing issue, providers may occasionally require assistance from the Medicare Administrator Contractor (MAC). In that case, Palmetto GBA will work with both providers/facilities for resolution. In addition, Palmetto GBA will work with other Medicare administrative contractors (MACs) when the overlapping claim is processed by another MAC. Complete and submit "Billing Dispute Resolution Request Form."

Last Reviewed: 07/15/2022

You must determine if the services were provided during the covered period of the SNF Part A stay or after the benefits exhausted, since consolidated billing rules may or may not apply. The SNF is required to bill “benefits exhaust” and/or “no pay” claims until the patient is discharged from the facility. In order to bypass Medicare edits, refile your corrected claim after the SNF has submitted or corrected their claims. In addition, it is recommended that you work with the SNF to help determine if the patient’s services were provided during the covered or non-covered portion of the stay and for claims resolution since timely filing rules apply.

Scenarios

  • Services were provided during the SNF covered Part A stay
    • SNF consolidated billing rules apply
  • Services were provided after the benefits exhausted
    • SNF is only responsible for billing physical, occupational and speech therapy services
    • All other services may be billed directly to the Medicare administrative contractor (MAC)
  • Services were provided after the patient was discharged
    • All services may be billed directly to the MAC

Benefits Exhaust
The SNF is only responsible for billing physical, occupational, and speech therapy services received during a non-covered stay. The beneficiary’s non-covered stay may be due to Part A benefits being exhausted, post hospital stay or the beneficiary did not meet SNF level of care requirements.

SNF Consolidated Billing
The consolidated billing requirements confer on the SNF’s billing responsibility for the entire package of care a resident receives during a covered Part A SNF stay.

The SNF must submit Medicare claims for all services rendered to their residents under a covered Part A SNF stay, except for certain excluded/separately payable services.

Refer to the CMS SNF Consolidated Billing for a list of excluded/separately payable services:

  • [CCYY] Part A MAC Update — Downloads
  • [CCYY] Part B MAC Update — Downloads

The SNF must either furnish the service directly with their own resources or obtain the service from an outside entity (such as a supplier) under an arrangement.

  • Under such arrangement, the SNF must reimburse the outside entity for those Medicare covered services subject to consolidated billing
    • Refer to the CMS SNF PPS Best Practices Guidelines for sample agreements if you need to establish payment arrangements with the SNF

Note: Absence of a valid arrangement does not invalidate the SNF’s responsibility to reimburse suppliers for services included in the SNF stay.

Resources: CMS internet-only manuals (IOM) 100-04, Chapter 6 (PDF) and Chapter 1 (PDF), MLN Matters Article MM4292 

Last Reviewed: 07/15/2022

Claims for inpatient hospital and skilled nursing facility (SNF) services have priority over claims for home health services, as beneficiaries cannot receive home care while they are institutionalized. Beneficiaries cannot be institutionalized and receive home care simultaneously.

  • Verify dates of service on your claim
    • If dates of service are incorrect, correct your claim and resubmit
    • If dates of service are correct, it is recommended that you contact the home health agency and ask them to correct their claim
  • Edit exclusions:
    • The inpatient claim admission date is the same as the HHA transfer/discharge date
    • The inpatient claim discharge date is the same as the home health agency admission date
    • The inpatient claim dates are between the occurrence span code 74 "From" date and the day following the occurrence span code "Through" date

Resource: CMS IOM, 100-04, Chapter 10 (PDF), section 30.9, and Chapter 25 (PDF).

Last Reviewed: 07/15/2022

Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.

When a beneficiary elects hospice during an inpatient stay:

  • Bill traditional Medicare for period before hospice election
  • Patient status code is 51 (discharge to hospice medical facility)
  • Discharge date is the effective date of hospice election
  • Bill hospice for period of care after hospice election

When a patient revokes hospice during an inpatient stay:

  • Bill hospice for period up to hospice revocation
  • Bill traditional Medicare for period after hospice revocation
  • Admission date is same as the hospice revocation date
  • Statement from date is the same as the hospice revocation date

See C7010 Claim Submission Error Help article for more information.

Resource: CMS IOM 100-02, Chapter 9 (PDF).

Last Reviewed: 07/15/2022

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

Resource: CMS IOM 100-04, Chapter 11 (PDF), section 30.4, 50.

Last Reviewed: 07/15/2022

You are responsible for determining the correct diagnostic and procedural coding for the services you furnish to Medicare patients. Medicare contractors cannot make determinations about the proper use of codes for you or your staff. If you have a question about interpretation of procedural and diagnostic coding, please contact the entities that have responsibility for those coding sets:
  • Current Procedural Terminology (CPT) codes are proprietary to the American Medical Association (AMA). As such, CPT coding questions should be referred to the AMA. The AMA offers CPT Information Services (CPT-IS). This internet-based service is a benefit to AMA members and is available as a subscription fee-based service for non-members and nonphysicians. The AMA also offers CPT Assistant. Information about these resources is found on the AMA's website.
  • The American Hospital Association (AHA) has a website with many resources for answers to coding questions. The website also has a direct link to the AHA Coding Clinic whereby coding questions may be submitted and tracked.
  • Level II Healthcare Common Procedure Coding System (HCPCS) codes related to durable medical equipment or prosthetics, orthotics, and supplies are answered by the Pricing, Data Analysis and Coding (PDAC) Contractor. Information about the PDAC Contractor and the services it provides can be found on the PDAC's website.
  • Additional information can be found about these resources on the CMS HCPCS General Information web page.

The information above can be found on the CMS IOM ManualsPublication 100-09, Chapter 6, and Section 30.1.1 (PDF).

Last Reviewed :07/15/2022

Bevacizumab (Avastin) represents 10mg per unit and should be billed one (1) unit for every 10 mg per patient. Claims for J9035 should be submitted so that the billed units represent the administered units, not the total number of milligrams.

Last Reviewed: 07/15/2022

No, if you identify an overpayment and want to make a voluntary refund.

Last Reviewed: 07/15/2022

This is a claim level reject reason code for claims that have all line items rejected with C7251, C7252, C7253, C7254, C7255, C7256 or C7257 received from the Common Working File (CWF). These rejections usually appear on the claim when the line item dates of service (LIDOS) are within the admission and discharge dates of another facility’s claim. For example, reason code C7251 will appear as the claim denial when the LIDOS of an outpatient claim (e.g., 12X, 13X, 14X, 22X, 23X, 34X, 74X, 75X, 83X and 85X) overlaps with a Part A skilled nursing facility (SNF) inpatient claim (21X) or when the outpatient claim LIDOS overlaps with an inpatient Part B (22X) claim.

Last Reviewed: 07/15/2022

Reason code 32512 states, 'type of bill is equal to outpatient, pricing indicator = Y, HCPCS code C9399 is present but associated units are greater than one. Units must be equal to one.'

HCPCS code C9399 should be used to report drugs and biologicals that have been approved by the Food and Drug Administration (FDA), but that do not yet have a product-specific drug/biological HCPCS assigned. Per Change Request (CR) 3287, HCPCS code C9399 should be reported as follows:

  • For the ANSI ASC X12N 837 I, hospital outpatient departments will report on type of bill (TOB) = 13x, containing revenue code 0636, HCPCS code C9399, and NDC number present in Loop 2400 LIN 03 of the 837 I
  • The hospital may report in the 'Remarks' section of the CMS-1450 or its electronic equivalent the National Drug Code (NDC) for the drug, the quantity of the drug that was administered, the unit of measure applicable to the drug or biological, and the date the drug was furnished to the beneficiary

When billing the applicable information for the unassigned drug on Page 2 in Direct Data Entry (DDE), providers should report one drug per revenue line. In addition, each occurrence of C9399 should be billed with a corresponding unit of one, regardless of the actual quantity of the drug that is administered.

Examples:
1.  Drug 'X' is approved by the FDA, but does not yet have a HCPCS code assigned. During the outpatient encounter on January 1, 2010, 5 units of the drug are administered.

 Rev  HCPCS Code  Unit  Serv Date
 0636  C9399  1  0101


2. Drug 'X' and Drug 'Y' are approved by the FDA, but do not yet have a HCPCS code assigned. During an outpatient encounter on March 1, 2010, five units of Drug 'X' are administered and three units of Drug 'Y' are administered.

 Rev  HCPCS Code  Unit  Serv Date
 0636  C9399   1  0101
 0636  C9399   1  0101

Note that the unit of one will essentially act as a placeholder and will direct Palmetto GBA to review the additional NDC information that will be present on the claim. In addition to the information included on Page 2, the provider should also include the NDC number, the quantity of the drug that was administered, the unit of measure applicable to the drug and the date the drug was furnished in both 'Remarks' and on the NDC page in DDE.

This information will be reviewed and used in the pricing of the unassigned drug(s). Palmetto GBA will manually calculate the payment for the drug or biological at 95 percent of the average wholesale price (AWP). The Fiscal Intermediary (FI) will pay 80 percent of that calculated payment to the hospital; beneficiaries will be responsible for the 20 percent co-pay after the deductible is met.

References:

  1. The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manuals, Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Section 90.2-90.3 (PDF)
  2. Change Request 3287 (PDF) – MMA: Hospital Outpatient Billing and Payment under Outpatient Prospective Payment System for New Drugs and Biologicals After FDA Approval but Before Assignment of a Product-Specific Drug/Biological HCPCS Code
  3. Change Request 6330 (PDF) – Clarification on Use of National Drug Codes (NDCs) in 837 I Billing

Last Reviewed: 07/15/2022

The CMS IOM 100-4 Medicare Claims Processing Manual, Chapter 1, Section 70.7.1 (PDF), contains what conditions contractors will allow for exceptions to and extensions of timely filing requirements.

The exceptions include:

  • Administrative error
  • Retroactive Medicare entitlement
  • Retroactive Medicare entitlement involving State Medicaid Agencies
  • Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization.
The CMS MSP Manual (Pub. 100-05), Chapter 3, Section 10.5 (PDF) also addresses this situation:

"In general, Medicare does not consider a situation where (a) Medicare processed a claim in accordance with the information on the claim form and consistent with the information in the Medicare's systems of records and; (b) a third party mistakenly paid primary when it alleges that Medicare should have been primary to constitute "good cause" to reopen." You may refer to:

Last Reviewed: 07/15/2022

The correct billing for drug screens, specifically HCPCS code G0431, should be billed per patient encounter and not for the number of drugs that are screened. HCPCS code G0431 may only be reported once per patient encounter. If a claim is submitted for the number of drugs screened instead of per patient encounter, the claim will deny.   
 
Last Reviewed: 07/15/2022

Part A providers may adjust claims, for the purpose of correcting clerical errors, within one year from the initial determination or within four years when good cause is supported.

While a contractor may choose to reopen a claim at any time under limited criteria, the Centers for Medicare & Medicaid Services (CMS) does not expect that a contractor would regularly grant reopening requests for older claims because its history may not be readily available. Both contractor and provider have a reasonable expectation to be timely in the administrative finality of their claims.

Third party payer error in making primary payment does not constitute good cause for the purpose of reopening a claim beyond one year of the initial determination or redetermination.  A contractor’s decision to reopen or not to reopen a claim, regardless of the reason for that decision, is not subject to appeal.

Adjustments to add services
If a provider fails to include a particular item or service on its initial bill, an adjustment request to include such item(s) or service(s) is not permitted after the expiration of the time limitation for filing a claim.

Hospital diagnosis related group (DRG) claim adjustments
Hospital adjustments to correct the diagnostic and procedure coding on their claim to a higher weighted DRG must be submitted within 60 days of the paid remittance.

Claim adjustments that result in a lower weighted DRG are not subject to the 60 days requirement.

Skilled nursing facility (SNF) health insurance prospective payment system (HIPPS) code adjustments
SNF adjustments to change a HIPPS code due to a minimum data set (MDS) correction must be completed within 120 days of the through date on the claim.

Provider requests for Medicare to grant a timely filing extension because a claim was canceled and/or revised and refiled after the one-year timely filing period due to the provider error; cannot be granted.

Time Limitations on Filing Adjustments

Reason For Adjustment
Time Limitation
(from Date of Service)
Adding additional items and services
1 Year
Incorrect bill type
1 Year
Third party error
1 Year
Correcting or supplementing information already billed
4 Years
Removing items and charges
4 Years
Adjustment for Inpatient PPS claims that result in a higher weighted Diagnostic Related Group (DRG)
60 days  - from Remittance Advice (RA) date on original claim
Adjustment to change Skilled Nursing Facility (SNF) Health Insurance Prospective Payment System (HIPPS) code
120 days - from “Through” date on claim

Please refer to CMS Internet-Only Manuals (IOM), Publication 100-04, Chapter 1 (PDF) Section 70.5 and Section 130; Chapter 34 (PDF), Sections 10.4 and 10.6.2.

Last Reviewed: 07/15/2022

The following two websites will provide guidance on the RAC process:

  1. Part A RAC Contractor website (Cotiviti Healthcare)
  2. The Centers for Medicare & Medicaid Services' RAC Home page

Last Reviewed: 07/15/2022