SNF Resource Utilization Groups Adjustment

Adjustment requests, based on corrected Skilled Nursing Facility (SNF) assessments that will increase the SNF payment, must be submitted to Noridian within 120 days from the through date indicated on a claim. The through date is used to calculate the period during which adjustment requests may be submitted based on corrected Resident Assessment Instrument (RAI) assessments. The through date indicates the last day of the billing period for which the Health Insurance Prospective Payment System (HIPPS) code is billed. For HIPPS changes resulting from a Minimum Data Set (MDS) correction, a provider's adjustment claim must include a condition code D2. A system edit limits the time for submitting this type of adjustment to 120 days from the service through date. If the adjustment is received after 120 days and is reducing the Medicare payment amount, the edit will be bypassed.

The CMS expects that most HIPPS code corrections will be made during the course of the beneficiary's Medicare Part A stay. Those providers that routinely submit corrections after the beneficiary's Part A stay has ended may be subject to focused medical review.

Adjustment requests to change a HIPPS code may not be submitted for any claim that has already been medically reviewed; such claims are identified in the Fiscal Intermediary Shared System (FISS) by an indicator on the claim record. This applies whether or not the medical review was performed either pre-payment or post-payment. All adjustment requests submitted are subject to medical review.

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Last Updated Thu, 25 Oct 2018 13:31:31 +0000