Medicare Billing Requirements for Beneficiaries Enrolled in MA

90.2 - Medicare Billing Requirements for Beneficiaries Enrolled in MA Plans (Rev.4491, Issued: 01-09- 20, Effective: 04-01-20, Implementation: 04-06-20) If a beneficiary chooses an MA plan as his or her form of Medicare, he/she cannot look to traditional “fee for service” Medicare to pay the claim if the MA plan denies coverage. SNF providers shall apply the following policies to MA beneficiaries who are admitted to a SNF: • If the SNF is non-participating with the plan, the beneficiary must be notified of his or her status because he/she MAY be private pay in this circumstance, depending upon the type of MA plan in which he/she is enrolled; • If the SNF is participating with the plan, pre-approve the SNF stay with the plan; • If the plan denies coverage, appeal to the plan, not to the “fee for service” FI; • Count the number of days paid by the plan as Part A days used (this IS 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. (Note: The plans do not send claims to CWF for SNF stays). 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 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 again requires skilled care after a period of non-skilled care, the provider should begin a new admission claim for Medicare to continue the spell of illness. Billing Requirements • Submit covered claims and include a HIPPS code (use default code AAA00 prior to 10/1/2019 and ZZZZZ after 10/1/2019) if no assessment was done), room and board charges and condition code 04. NOTE: If the beneficiary drops his or her MA plan participation during their SNF stay, the beneficiary is entitled to coverage under Medicare FFS for the number of days available that remain out of the 100 days available under the SNF benefit.