Billing When Ban on Payment Is In Effect

50.2 - Billing When Ban on Payment Is In Effect (Rev. 1555; Issued: 07-18-08; Effective Date: 01-01-09; Implementation Date: 01- 05-09) Beneficiaries admitted before the effective date of the denial of payment and taking temporary leave, whether to receive inpatient hospital care, outpatient services or as therapeutic leave, are not considered new admissions, and are not subject to the denial of payment upon return. This policy applies even if there are multiple hospitalizations and returns to the SNF during the period sanctions are in effect. When determining if the beneficiary was admitted prior to the imposition of the ban, the actual status of the beneficiary rather than the primary payor is the determining factor. Therefore, there may be situations where the beneficiary is a private pay patient or a dual eligible who was receiving Medicaid benefits prior to the imposition of the payment ban. If this private pay patient or dual eligible goes to the hospital for needed care, and meets the Medicare Part A criteria for SNF coverage upon return to the SNF, the readmission is exempt from the denial of payment sanction. When billing for a readmission that is NOT subject to the payment ban, providers must enter occurrence span code 80, Prior Same- SNF Stay Dates for Payment Ban Purposes, on the claim to identify the prior same-SNF stay dates, in addition to reporting any LOA and prior hospital stay dates, using occurrence span codes, that may affect the A/B MACs (A)’s determination of payment ban exemption status. See Chapter 25 of this manual for occurrence span code titles and definitions.