Types of SNF PPS Review

6.1.2 - Types of SNF PPS Review (Rev. 924; Issued: 11-15-19; Effective: 10-01-19; Implementation: 12-17-19) A. Targeted Probe and Educate Medical Review Medicare Administrative Contractors (MACs) shall follow the instructions described in Chapter 3 of Pub. 100-08, the Medicare Program Integrity Manual, when conducting medical review. B. Demand Bills MACs must conduct MR of all patient-generated demand bills with the following exception: Demand bills for services to beneficiaries who are not entitled to Medicare or do not meet eligibility requirements for payment of SNF benefits (i.e., no qualifying hospital stay) do not require MR. A denial notice with the appropriate reasons for denial must be sent. Demand bills are bills submitted by the SNF at the beneficiary’s request because the beneficiary disputes the provider’s opinion that the bill will not be paid by Medicare and requests that the bill be submitted for a payment determination. The demand bill is identified by the presence of a condition code 20. The SNF must have the proper liability notice consistent with Section 1879 of the Social Security Act signed by the beneficiary unless the beneficiary is deceased or incapable of signing. In this case, the beneficiary’s guardian, relative, or other authorized representative may make the request (see 42 CFR 424.36, Signature requirements). In the case where all covered services are being terminated, the SNF provider is also required to have issued an expedited determinations notice, as detailed in Pub. 100-04, Medicare Claims Processing Manual, chapter 30, section 260, and on the CMS website at https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-Expedited- Determination-Notices.html. When determining eligibility for Medicare coverage, the MAC shall review the demand bill and the medical record to determine that both technical and clinical criteria are met. If all technical and clinical criteria are met, and the reviewer determines that some or all services provided were reasonable and necessary, use the MDS QC System Software, as necessary, to determine the appropriate case-mix classifier. Further instruction on the use of this software for adjustment of SNF claims is found in section 6.1.3 below. If the reviewer determines that no services provided were medically necessary, the MAC shall deny the claim in full. The Health Insurance Prospective Payment System (HIPPS) code and revenue code 0022 must be present on the demand bill. There may be cases where the MAC receives a demand bill for which no associated MDS (or other required Medicare assessment) was transmitted to the repository because the provider did not feel that the services were appropriate for Medicare payment. In these cases, if the Medicare contractor determines that coverage criteria are met (see § 6.1.4 B.), and medically necessary skilled services were provided, the Medicare contractor shall pay the claim at the default rate for the period of covered care for which there is no associated MDS in the repository. C. Claims Submitted for Medicare Denial Notices Providers may submit claims for a denial from Medicare for Medicaid or another insurer that requires a Medicare denial notice. These claims are identified by condition code 21. The SNF is required to issue a notice of noncoverage to the beneficiary that includes the specific reasons the services were determined to be noncovered. A copy of this notice must be maintained on file by the SNF in case the Medicare contractor requests a copy of the notice. See Pub. 100-04, Medicare Claims Processing Manual, chapter 1, §60.1.3 for further details.