Freestanding Psychiatric Hospitals Lifetime Limit

The psychiatric lifetime maximum benefit applies to psychiatric hospitals per 42 CFR 409.62. Section 409.62 states, "There is a lifetime maximum of 190 days on inpatient psychiatric hospital services available to any beneficiary. Therefore, once an individual receives benefits for 190 days of care in a psychiatric hospital, no further benefits of that type are available to that individual."

The regulation means that payment may not be made for more than a total of 190 days of inpatient psychiatric hospital services during the patient's lifetime. This limitation applies only to services furnished in a psychiatric hospital. The 190-day lifetime limitation does not apply to psychiatric distinct part units.

If a provider self-identifies an overpayment as a result of benefits paid beyond the lifetime maximum of 190 days of inpatient psychiatric hospital services, Section 1128J of the Social Security Act (42 USC § 1320a-7k(d)) requires Medicare providers, suppliers, and plans to report and return the self-identified overpayments. This statutory provision imposes an obligation on providers, suppliers and plans to report and return overpayments under the Medicare and Medicaid programs within 60 days of identifying the overpayment. Overpayments should be returned to the following address based on your State Mailing Address.

Along with the check payment, include a letter of explanation as to how the overpayment amount was determined. If claims need to be adjusted, include the Voluntary Refund information. See the Voluntary Refund/Self-Disclosure Process webpage.

To prevent future claim payments for beneficiaries that have reached the 190-day lifetime psychiatric limit, submit a no-pay claim as follows:

  • Type of Bill (TOB) 110
  • Condition code 21
  • All charges in non-covered
  • Basic required claim elements

 

Last Updated Tue, 10 Apr 2018 08:43:03 +0000