Billing Reminder: When a Skilled Nursing Facility Payment Ban is in Effect
CMS may impose a DPNA against the SNF when the facility is not in compliance with the requirements of participation under the Social Security Act at Sections 1819(h) and 1919(h) and CMS’ regulations at 42 CFR 488.417.
The information related to this Nursing Home Enforcement can be located on the CMS website at:
Table of Contents
- The Effect on Utilization Days and the Benefit Period
- Billing Requirements When the Ban on Payment is in Effect
- Provider Liability Billing Instructions
- Beneficiary Liability Billing Instructions
- Billing When the Sanctions are Lifted
- Related Content
The Effect on Utilization Days and the Benefit Period
Payment sanctions are applied to the days that would otherwise be payable under Part A, i.e., the care is covered but no payment will be made to the provider. If the SNF assumes responsibility for the beneficiary’s costs during the sanction period, it is considered to be the same as a program payment, and the days will count towards the beneficiary’s 100-day benefit period.
When the SNF fails to issue the proper beneficiary liability notice, the provider is liable for all services that are normally covered under the Medicare Part A benefit. The days are considered Part A days and charged against the beneficiary’s benefit period since the beneficiary is receiving benefits. The SNF may collect any applicable copayment amounts.
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 are not be charged towards the 100-day benefit period.
Billing Requirements When the Ban on Payment is in Effect
Beneficiaries admitted before the effective date of the DPNA and that take 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 DPNA upon their return to the SNF. This would apply even if there are multiple hospitalizations and returns to the SNF during the period where sanctions are in effect.
When determining if the beneficiary was admitted prior to the ban, the determining factor is the actual status of the beneficiary rather than the primary payor.
In addition, there may be certain situations where the beneficiary is a private pay patient or a dual eligible who was receiving Medicaid benefits prior to imposition of the payment ban. If this private pay or dual eligible patient goes to the hospital for needed care, and meets the Medicare Part A criteria for SNF coverage upon return, the readmission is exempt from the denial of payment sanction.
When the SNF is billing for a readmission that is not subject to the DPNA providers must enter the following information on the UB04 claim form:
- Occurrence span code 80 (prior same SNF stay dates) on the claim to identify the prior same-SNF stay dates
- In addition report any other applicable occurrence span codes e.g., prior hospital stay, LOA
Provider Liability Billing Instructions
When the SNF failed to issue the proper beneficiary liability notice and the SNF facility is liable for the services. Any applicable copayment will be charged to the beneficiary’s Part A benefit period. The SNF must enter the following information on the UB04 claim form:
- Covered type of bill (TOB) – 21X
- Occurrence span code 77 indicating the facility is liable for the services
- 0022 revenue code with the covered days
- Room and board revenue code, i.e., 0120 for the total number of days for the statement covered period
The sum of all covered units reported on all revenue code 0022 lines should be equal to the covered days. This does not include the number of provider liable days reported in the occurrence span code 77.
When the SNF is liable for the Part A stay, the SNF must provide all necessary covered Part A services, including those services mandated under consolidated billing. In addition the SNF can’t charge the beneficiary for any services that in the absence of the of the payment ban would have been covered under Part A PPS. The beneficiary may be liable for coinsurance.
Beneficiary Liability Billing Instructions
The SNF should file a no-payment bill for the noncovered Part A services when the beneficiary is liable. The following information must be entered on the UB04 claim form by the SNF:
- No-payment TOB– 210
- Condition Code (CC) 21 indicating the beneficiary is liable
- All charges billed as noncovered
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.
Billing When the Sanctions are Lifted
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.
Medicare payments for eligible beneficiaries who are new admissions to the SNF should begin on the date the sanction is lifted.
All technical eligibility requirements (e.g., a three-day hospital stay, etc.) must be met. In addition, all services must be reasonable and necessary and the beneficiary must be receiving skilled care.
Related Content
Refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section, 50 – 50.7 for additional information on assessments, tracking benefit periods, transfer requirements and the physician certification.
Posted 9/8/2021