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Overlapping Claim Resolution Tips

This Job Aid is intended for those providers who experience claim rejections for overlapping dates of service. View tips that can be used to resolve and avoid such situations.

Overlapping situations can occur for any number of reasons. The most common reasons for which an overlapping situation can occur are provided below.

Types of Bills (TOBs) Impacted

Overlapping situations may apply to TOBs.

  • 11X, 13X, 21X, 32X, 72X, 74X, 75X, 81X, 82X, 85X

Overlapping Situations

An overlapping situation may occur between hospitals for inpatient stays, which include [Inpatient Psychiatric Hospitals (IPH), Long Term Care Hospitals (LTCH), Inpatient Rehab Facilities (IRF), Critical Access Hospital (CAH)], hospitals for outpatient services, Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs), Hospice agencies, Outpatient Rehab Facilities (ORF), Comprehensive Outpatient Rehab Facilities (CORF), End Stage Renal Disease (ESRD) Facilities, or a combination of one provider type and another. Overlapping situations may also occur due to SNF or Home Health consolidated billing, or the Place of Service (POS) submitted on physician claims where the SNF or Home Health has failed to properly discharge the beneficiary.

Note: If the patient is in a Home Health or SNF, payment arrangements must be agreed upon by both the provider and the supplier.

All Provider Types

Medicare providers are expected to verify a beneficiary's Medicare eligibility at the time of or prior to admission to ensure that the patient is eligible to receive the services covered by Medicare. Checking the beneficiary's eligibility records also ensures that the facility/agency verifies if the patient is receiving services from another entity that would cause an overlapping situation.

Medicare providers are expected to work together to resolve overlap situations. When a billing dispute arises between Medicare providers for dates of services or patient discharge status and neither party can reach a resolution, the Medicare contractor is tasked with assisting the providers with resolving the matter. Providers are encouraged to seek assistance from Noridian as soon as it is evident that a resolution cannot be reached. Requests received for claims that are past the timely filing limit will not be processed without good cause as defined in the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 70.7.

To request assistance with resolving a billing dispute, call the Provider Contact Center. Be prepared to provide documentation as incomplete requests will not be processed. Your request will be processed within 45 calendar days of the date it was received and we will notify you of the outcome via phone. Your MAC may request additional documentation including call logs, letters, or bill attempts, and supporting medical records including transfer agreements, admission orders or discharge summaries.

Resolution Tips by Provider Type

All Provider Types Overlapping a Hospice

Providers of all types whose claims are overlapping a hospice election should contact the Hospice agency to determine if the services are related to the terminal illness. If related, payment arrangements should be made with the hospice provider. Services that are not related to the terminal illness should be billed with a 07 Condition Code. See CMS IOM Publication 100-04, Chapter 11, Section 30.3.

Providers who suspect that the hospice may no longer be in business and are unable to verify if their services are related, or if the hospice has failed to update the revocation indicator should contact their MAC for assistance.

ESRD Facilities

  • ESRD Overlapping with an Inpatient Hospital: When a patient is in the hospital a separate payment cannot be made for dialysis services unless the services are excluded from SNF consolidated billing. The ESRD facility can be paid for the date of admission to or the date of discharge from an inpatient hospital; however, the hospitals are responsible for providing dialysis services to a patient while he/she is under inpatient care. See CMS IOM, Publication 100-04, Chapter 8, Section 10.5

Home Health Agencies (HHAs)

  • Home Health Transfer Situation: Only the patient can elect to transfer from one HHA to another. See CMS IOM, Publication 100-02, Chapter 7, Section 10.8 E
    • When patient has elected to transfer from one HHA to another, receiving HHA is required to:
      1. Access patient's eligibility records in Direct Data Entry (DDE) system, print and save a copy of page that validates if patient is under an established home health plan of care
      2. Contact transferring agency to arrange for a transfer date
      3. Document name of individual with whom they communicate, date and time of contact and date of transfer
      4. Inform patient that initial HHA will no longer receive Medicare payment or provide services after date of elected transfer
      5. Document in patient's file that he/she was notified of transfer criteria and possible payment implications
      6. Send a copy of transfer agreement to transferring agency
    • The transferring agency is required to document the following:
      1. Date and time that receiving HHA contacted them to inform them of transfer
      2. Name of individual from receiving agency
      3. Date agreed upon for transfer
      4. Retain a copy of transfer agreement
  • Home Health Overlapping Inpatient Hospital or SNF Part A Stay: HHAs can be paid for the date of admission to an inpatient facility or the date of discharge from an inpatient facility. The HHA cannot provide services to the patient while he/she is in an inpatient facility. The HHA omits any dates of service from their claim that fall on the days between the admission and discharge dates for an inpatient facility. See CMS IOM, Publication 100-04, Chapter 10, Section 30.9
  • Home Health Overlapping with ORF or CORF: Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a home health plan of care. If therapy services are needed from an ORF, the HHA and the ORF must enter into an agreement where services will be paid to the HHA and the HHA will reimburse the ORF
  • Home Health Consolidated Billing: For individuals under a home health plan of care, payment for all services and supplies, with the exception of osteoporosis drugs, DME, and furnishing NPWT using a disposable device is included in the HH PPS base payment rates. HHAs must provide the covered home health services (except DME) either directly or under arrangement, and must bill for such covered home health services. See CMS IOM, Publication 100-02, Chapter 7, Section 10.11 and Home Health Consolidated Billing Master Code List

Hospices

  • Hospice Transfer Situation: Hospices are expected to ensure that they are verifying a beneficiary's status in the hospice program. When the patient has chosen to change hospices during an election period, the transferring and receiving hospice are expected to agree upon a transfer date before the transfer takes place. The beneficiary or authorized representative is required to ensure that a transfer notice is on file with both hospices at the time of the transfer. Given that hospice beneficiaries are terminally ill and may not be in a position to complete the necessary transfer notification, hospice agencies are encouraged to assist the patient or representative with completing the transfer agreement and notifying the other hospice. See CMS IOM, Publication 100-02, Chapter 9, Section 20.1
  • Hospice Overlapping with Other Provider Types: Hospices should not encounter overlapping situations with other provider types as hospice care can be provided in any location that the beneficiary/patient resides whether temporarily or permanently. Once enrolled in the Hospice Medicare Benefit, the hospice is responsible for managing the patient's care that is related to the terminal illness. All services related to the terminal illness are to be billed to Medicare by the hospice agency. The hospice should also coordinate with other providers for services that are not related to the terminal illness to ensure accurate billing of non-related services

Inpatient Hospitals

  • Hospital Transfer Situation: Hospitals should ensure that the transfer requirements have been met before the transfer takes place. The transferring hospital cannot be paid for the actual date of transfer. The receiving hospital can be paid for the date of the transfer, but not the date of discharge. Hospitals should also ensure that they are submitting their discharge claims with the appropriate discharge status code reflecting the same day admission to the subsequent facility. See CMS IOM, Publication 100-04, Chapter 3, Section 20.1.2.4
  • Hospital Discharge Coding: Hospitals should ensure that the patient status is billed accurately for proper payment. If the hospital learns that post-acute care was provided (i.e. left against medical advice, discharged but later readmitted the same day to another IPPS hospital, transferred), the hospital should submit an adjustment bill to correct the discharge status code. See MLN Matters Special Edition (SE)1411
  • Hospital Overlapping with Home Health Care: A patient cannot receive home health care while he/she is in an inpatient hospital stay. When the patient is in the hospital that falls within a 60-day episode of care, the home health agency is required to omit those dates from their final (end of episode) claim. However, both the hospital and the home health agency can be paid for the date of admission to the hospital stay. The home health agency can also receive payment for services rendered to a patient on the date of discharge from an inpatient hospital stay. See CMS IOM, Publication 100-04, Chapter 10, Section 30.9
  • Hospital Overlapping with a Long-Term Care Hospital (LTCH): When a patient is admitted to an inpatient acute care hospital, upon discharge from an LTCH and is readmitted to the same LTCH within 3 days, payment is made to the LTCH. The hospital may not bill Medicare, but must look to the LTCH for payment of services. The only exception to this rule is when treatment at an inpatient acute care hospital would be grouped to a surgical DRG. See CMS IOM, Publication 100-04, Chapter 3, Section 150.9.1.2
  • Hospital Overlapping with an Inpatient Psychiatric Facility (IPF): When the stay is for 3 days or less, verify the IPF has added Occurrence Span Code (OSC) 74 with the associated dates of service. See CMS IOM, Publication 100-04, Chapter 3, Section 190.7.1
  • Hospital Overlapping with an Inpatient Rehabilitation Facility (IRF): When the stay is for 3 days or less, verify the IRF has added Occurrence Span Code 74 with the associated dates of service and the hospital bills Medicare. When the patient is discharged and returns to the same IRF on the same day, the other facility will need to look to the IRF for payment of services. See CMS IOM, Publication 100-04, Chapter 3, Section 140.2.4
  • Hospital Overlapping with Outpatient Services: A patient cannot receive inpatient and outpatient services at the same time. In situations where the patient is in outpatient status and later admitted to the same facility as an inpatient without a break in service, all charges are billed on the inpatient claim. Exception: Outpatient diagnostic services furnished provided more than 3 days preceding the date of the admission are not part of the payment window. See CMS IOM, Publication 100-04, Chapter 3, Section 40.3

    In situations where the inpatient hospital does not have the technology to perform a procedure and transfers the patient for completion of the procedure, and the patient returns as inpatient, the outpatient hospital must look to the inpatient facility for payment under arrangement
  • Hospital Overlapping with a SNF: The hospital should ensure that they have submitted the correct admit and discharge dates on their claim. In addition, the correct discharge patient status code must be billed on the claim. If the patient was transferred from a SNF and returned to the SNF prior to midnight, the hospital must bill a Same Day Transfer. See CMS IOM, Publication 100-04, Chapter 3, Section 40.1
  • Repeat Admissions/Leave of Absence: Hospitals may place a patient on a leave of absence when readmission is expected and the patient does not require a hospital level of care during the interim period. Institutional providers must not use the leave of absence billing procedure when the second admission is unexpected. See CMS IOM, Publication 100-04, Chapter 3, Section 40.2.5
  • Same-day, Same-Provider Acute Care Readmissions:
    • If patient is readmitted on same day for symptoms related to prior admission then facility must combine bills to create one continuous stay and the other facility must bill the hospital under arrangement
    • If patient is readmitted on same day for symptoms NOT related to prior admission then two separate claims are required with the second claim having condition code B4. The other facility will bill same day transfer

Outpatient Hospitals

  • Hospital Outpatient Overlapping Hospital Inpatient Including Acute, IRF, IPF, and LTCH: A patient cannot receive outpatient services simultaneously while admitted to an inpatient facility. Situations arise when an inpatient facility transfers a patient for an outpatient procedure during an inpatient admission. The outpatient facility should look to the inpatient facility for payment under arrangements. See CMS IOM, Publication 100-04, Chapter 4, Section 10.2
  • Hospital Outpatient Overlapping a SNF Part A Stay: A patient may receive outpatient hospital are during a covered Part A SNF stay. Certain services maybe part of SNF consolidated billing, and therefore payment received for those services, should be made by the SNF to the outpatient facility. See CMS SNF Consolidated Billing webpage

Outpatient Rehab Facilities and Comprehensive Outpatient Rehab

  • ORF or CORF Overlapping with SNF: Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a SNF Part A Stay in a Medicare certified bed. If therapy services are needed from an ORF or CORF, the SNF and the ORF or CORF must enter into an agreement where services will be paid to the SNF and the SNF will reimburse the ORF or CORF
  • ORF or CORF Overlapping with Home Health Services: Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a home health plan of care. If therapy services are needed from an ORF or CORF, the HHA and the ORF or CORF must enter into an agreement where services will be paid to the HHA and the HHA will reimburse the ORF or CORF. See CMS IOM, Publication 100-02, Chapter 7, Section 10.11

SNFs

  • SNF Transfer Situation: SNFs should ensure that the transfer requirements are met before the transfer takes place. The transferring SNF cannot be paid for the actual date of transfer. The receiving SNF can be paid for the date of the transfer, but not the date of discharge. SNFs should also ensure that they are submitting their discharge claims with the appropriate discharge status code. See CMS IOM, Publication 100-04, Chapter 6, Section 40.3.4

    If the patient was admitted to the hospital and returned to the SNF prior to midnight, the SNF would need to submit a discharge claim and then submit a new claim with a new Admit Date (this would be considered a readmission and the 57 condition code may need applied). As a reminder, inpatient admission to a hospital or admission to another SNF forces a discharge from a SNF. See CMS IOM, Publication 100-04, Chapter 6, Section 40.3.2
  • SNF Overlapping with Home Health Care: A patient cannot receive home health care while in a SNF regardless of whether the patient is under a Medicare Part A stay. The home health agency is required to omit dates of service from their claim while the patient is under the care of the SNF between the admit and discharge dates. See CMS IOM. Publication 100-04, Chapter 6, Section 40.3.4
  • SNF Overlapping with an Inpatient Hospital: SNFs can be paid for the date of admission from a hospital, but not the date of discharge should the patient return to the hospital from the SNF. SNFs must also ensure that they are submitting their claims with the correct discharge status code when a patient is returned to the hospital. See CMS IOM, Publication 100-04, Chapter 6, Section 40.3.3
  • SNF Overlapping with ORF or CORF: Therapy falls under the consolidated billing requirements, and therefore cannot be paid separately when a patient is under a SNF Part A Stay in a Medicare certified bed. If therapy services are needed from an ORF, the SNF and the ORF must enter into an agreement where services will be paid to the SNF and the SNF will reimburse the ORF. Arrangement examples can be found on the CMS Best Practices Guidelines. See CMS IOM, Publication 100-04, Chapter 6, Section 10.1
  • SNF Overlapping with LTCH: When a patient is admitted to a SNF upon discharge from an LTCH and is readmitted to the same LTCH within 3 days, payment is made to the LTCH. The SNF must look to the LTCH for payment. See CMS IOM Publication 100-04, Chapter 3, Section 150.9.1.2
  • SNF Consolidated Billing: The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care that residents receive during a Part SNF stay and physical, occupational, and speech therapy services received during a non-covered stay. There are a limited number of services specifically excluded from consolidated billing, and therefore, separately payable. See CMS SNF Consolidated Billing webpage
     

Last Updated Thu, 05 Mar 2020 16:51:51 +0000