Application of Limitation on Liability to SNF and Hospital

130.3 - Application of Limitation on Liability to SNF and Hospital Claims for Services Furnished in Noncertified or Inappropriately Certified Beds (Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18) A. General Payment for SNF and hospital claims may not be denied solely on the basis of a beneficiary’s placement in a non-certified portion of the same institution that also includes a participating SNF or hospital. When requested by the beneficiary or his/her authorized representative, a provider must submit a claim to the A/B MAC (A) for services rendered in a non-certified bed. When the A/B MAC (A) reviews a claim for services rendered in a non-certified bed, it first determines whether the beneficiary consented to the placement. (See subsection C.) If the A/B MAC (A) finds that the beneficiary consented, it denies the claim. If it finds that the beneficiary did not consent, it determines whether there are any other reasons for denying the claim. (See subsection D.) If there is another reason for denying the claim, the A/B MAC (A) denies it. However, if none of the reasons for denial exist, beneficiary liability must be waived as provided under §1879(e) of the Act and a further determination must be made as to whether the provider, rather than the Medicare program, must accept liability for the services in question. (See “Coverage of Extended Care Services Under Hospital Insurance” in the Medicare Benefit Policy Manual, Chapter 8.) B. Provider Notice Requirements When a SNF or hospital places a patient in a noncertified or inappropriately certified portion of the institution because it believes the patient does not require a covered level of care, or for any other reason, it must notify the patient (or authorized representative) in writing that services in a noncertified or inappropriately certified bed are not covered. The provider uses the appropriate notice specified in §70 for SNFs or swing beds, §80 for inpatient hospitals, to advise the beneficiary of its decision to place him/her in a noncertified bed, using language such as: We are placing you in a part of the institution that is not appropriately certified by Medicare because (you do not require a level of care that will qualify as skilled nursing care/or covered hospital services under Medicare)/(or state any other reasons for the noncertified bed placement). Nonqualifying services furnished a patient in a noncertified or inappropriately certified bed are not payable by Medicare. However, you may request us to file a claim for Medicare benefits. Based on this claim, Medicare will make a formal determination and advise whether any benefits are payable to you. (For related general billing requirements, see Chapter 1, §60 of this manual, or other chapters specific to the benefit being billed: Chapter 3 for inpatient hospitals and swing beds, Chapter 6 for swing bed PPS and inpatient SNFs, and Chapter 7 for outpatient SNFs.) C. Determining Beneficiary Consent The CMS presumes that the beneficiary did not consent to being placed in a noncertified bed. In order to rebut the presumption of lack of consent, the provider must indicate on the bill the date it provided the beneficiary with an ABN notifying the beneficiary that the accommodations would no longer be covered; and requested the beneficiary’s signed acknowledgement (on the ABN) of having received such a statement. Moreover, in any case in which a Medicare beneficiary gives his/her consent to placement in a noncertified bed, the provider must, if requested by the A/B MAC (A) (contemplated only at an appeal level of claim processing), submit a copy of the ABN signed by the beneficiary to the A/B MAC (A), for a determination of the ABN’s validity. The ABN must be signed by the beneficiary (provided he/she is competent to give such consent) or by the beneficiary’s authorized representative. If the beneficiary or his/her authorized representative refuses to sign the form, the provider may annotate the file to indicate it presented the ABN to the beneficiary (or his/her authorized representative), but the beneficiary refused to sign. As long as the provider’s ABN notifies the beneficiary of the likely Medicare noncoverage, the beneficiary’s refusal to sign the ABN does not render it invalid. (See §40.3.4.6.) If any of the above requirements is not met, the A/B MAC (A) automatically determines the ABN is defective. When the A/B MAC (A) receives a claim with an indication that the provider has provided the beneficiary or his/her authorized representative, with an ABN, the A/B MAC (A) denies the claim and notifies the beneficiary that §1879 limitation on liability cannot be applied because of the beneficiary’s valid consent to be cared for in a noncertified or inappropriately certified bed. If the A/B MAC (A) determines that the ABN is not valid, the A/B MAC (A) processes the claim in accordance with §130.4. If the beneficiary appeals the initial denial, the A/B MAC (A) obtains the ABN from the provider and determines whether it is valid. If the A/B MAC (A) determines that the ABN is invalid, it notifies the provider and the beneficiary that payment may be made to the extent that all other requirements are met. D. Determining Whether Other Requirements for Payment are Met Denials still are appropriate for any of the following reasons. The A/B MAC (A) must undertake the development needed to permit a determination as to whether: • The patient did not receive or require otherwise covered hospital services or a covered level of SNF care; • The benefits are exhausted; • The physician’s certification requirement is not met; • There was no qualifying 3-day hospital stay (applicable to SNFs only); or • Transfer from the hospital to the SNF was not made on a timely basis. (However, if transfer to an institution which contains a participating SNF is made on a timely basis, a claim cannot be denied solely on the grounds that the transfer requirement is not met because the bed in which the beneficiary is placed is not a certified SNF bed.) The A/B MAC (A) denies cases falling within these categories under existing procedures. Also, if the beneficiary receives care in a totally nonparticipating institution, denial on the grounds that the beneficiary was not in a participating SNF or hospital is still appropriate.