Skilled Nursing Facility Services and Medicare Advantage Plans

Providers are required to submit claims correctly to Medicare. Sending an informational only claim with condition code 04 shows the provider has knowledge the beneficiary is enrolled in a Medicare Advantage (MA) Plan. Billing requirements including the use of condition code 04 are found in the CMS Internet Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 90.2.

Medicare Policy

The following policies are applicable for Skilled Nursing Facility (SNF) providers regarding MA beneficiaries who are admitted to a SNF:

  • If the SNF is non-participating with the plan
    • The beneficiary must be notified because the stay may be private pay in this circumstance, depending upon the type of enrolled MA plan
  • If the SNF is participating with the MA plan
    • Pre-approve the SNF stay with the MA plan
  • If the plan denies coverage
    • Appeal the specific MA plan, not Noridian
  • Count the number of days paid by the plan as Part A days used against the beneficiary’s 100 days of Medicare SNF benefits
  • Submit a claim to the “Fee-For-Service A/B MAC (A) to subtract benefit days from the CWF records. Failure to send a claim to the A/B MAC (A) will inaccurately show days available.
  • If a beneficiary, no longer requires skilled care under the MA plan the SNF may discharge the patient using a patient discharge status code 04.
  • No-payment bills are not required for beneficiaries that are receiving non-skilled care and are enrolled in an MA plan.
  • If the beneficiary requires skilled care after a period of 60 days of non-skilled care, the provider should begin a new admission claim.

Billing Requirements

Correct billing tips to avoid unprocessable claims. Submit charges as covered (room and board) include:

  • Type of bill 011X
  • Condition code 04 (information only bill)
  • Condition code 69 (teaching hospitals only)
  • Include Health Insurance Prospective Payment System (HIPPS) code
    • Use default code if no assessment was done


Last Updated Thu, 01 Oct 2020 14:50:30 +0000