Skilled Nursing Facility (SNF) and Medicare Advantage (MA) Plans - JE Part A

Medicare requires providers submit claims correctly. SNFs submit two claims for MA beneficiaries in a covered Part A stay. The first claim is to the MA plan for payment. The second claim is sometimes called an informational claim or a shadow claim. This second claim is submitted to the Medicare Administrative Contractor (i.e., Noridian) to update the beneficiary’s benefit period on common working file (CWF). Billing requirements for MA beneficiaries are found in CMS Internet Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 90.

Medicare Advantage Information-Only Claims

The following policies are applicable for SNF providers regarding MA beneficiaries admitted to a SNF:

• SNF is non-participating with the MA plan
  • Notify the beneficiary, the stay may be private pay in this circumstance
• SNF is participating with the MA plan
  • Pre-approve the SNF stay with the MA plan
    • If the plan denies coverage
      • Submit appeal to the MA plan, not Noridian
    • Submit payment claim to MA plan
    • Submit informational claim to Noridian
      • Updates beneficiary’s benefit days on CWF
      • Failure to send this claim inaccurately shows days available
• MA beneficiary no longer requires skilled care
  • May discharge with a 04-patient discharge status code (intermediate care facility (ICF) level of care)
• Beneficiary requires skilled care after a period of non-skilled care
  • Submit a new admission claim

Billing Requirements

• Beneficiary receiving covered Part A SNF services
  • Covered type of bill 021X
  • Condition code 04 (informational-only bill)
  • List charges and days as covered
  • Show Medicare as primary payer
    • Do not list the MA plan
  • Include Health Insurance Prospective Payment System (HIPPS) code
    • No assessment done - use default code ZZZZZ
  • Submit monthly as normal covered claim
• Beneficiary receiving non-skilled care
  • Informational-only claims not required
  • May submit discharge claim with a 04 patient discharge status code (intermediate care facility (ICF) level of care)
• Beneficiary requires skilled care after period of non-skilled care
  • Submit new admission claim
• Beneficiary exhausts MA benefits and still receiving skilled level of care
  • Continue sending monthly informational-only claims to keep CWF updated
• Beneficiary disenrolls from MA plan
  • Any days remaining of the 100 benefit days are available to the beneficiary
  • If MA plan did not require a qualifying hospital stay (QHS)
    • Append condition code 58 to bypass the edit