A/B MACs to Return Certain Telehealth and Acute Hospital Care at Home (AHCAH) Claims to Providers

In an effort to resolve a rolling October claims hold and improve cash flow for providers, CMS has directed A/B MACs to return to providers the remaining subset of telehealth claims and AHCAH claims currently being held.

Telehealth Claims:

Part A/B MACs shall return to providers the remaining telehealth claims that are being held as follows:

Part B MACs shall append the following CARC/RARC combination:

CARC 16: Claim/service lacks information or has submission/billing error(s). Usage: Do not use this code for claims attachment(s)/other documentation. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC M77: Missing/incomplete/invalid/inappropriate place of service.

Part A MACs shall develop local editing to return-to-provider (RTP) any remaining telehealth claims.

Acute Hospital Care at Home (AHCAH)

Part A MACs shall no longer hold claims billed for AHCAH and are instructed to develop local editing to RTP inpatient claims submitted for AHCAH as follows:

  • Bill type is 11X (excluding 110 for denials),
  • Discharge date is on or after 10/01/2025, and
  • Revenue code 0161 is reported for dates of service on or after 10/01/2025 as reflected in the Occurrence Span Code (OSC) 82 dates.

Note: Claims billed for a denial notice shall be allowed to process. Providers will receive education in regard to Advance Beneficiary Notice (ABN) of Noncoverage for acute hospital care where the patient was not discharged or returned to the hospital.

For additional information, read the official Spotlight announcement posted on CMS’s Fee-For-Service Providers webpage.

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