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Resolution Tips for Overlapping Claims

A/B & HHH MAC collaborative job aid for overlapping claims

Introduction

The purpose of this article is to give providers tips on resolving claim rejections for overlapping dates of service. 

Overlapping situations can occur for any number of reasons. This article contains information on the most common reasons for which an overlapping situation can occur.

Impacted Type of Bills (TOBs)

The overlapping situations may apply to TOBs 11X, 13X, 21X, 32X, 72X, 74X, 75X, 81X, 82X, and 85X.

Overlapping Situations

An overlapping situation may occur between hospitals for inpatient stays, which include the following provider types or a combination of provider types:

  • Inpatient psychiatric facility (IPF) 
  • Long term care hospital (LTCH) 
  • Inpatient rehab facility (IRF) 
  • Critical access hospital (CAH) 
  • Hospitals for outpatient services 
  • Skilled nursing facility (SNF) 
  • Home health agency (HHA) 
  • Hospice agency 
  • Outpatient rehab facility (ORF) 
  • Comprehensive outpatient rehab facility (CORF) 
  • End stage renal disease (ESRD) facility

Overlapping situations may also occur due to SNF or home health consolidated billing, or the place of service (POS) submitted on physician claims when a SNF or HHA has not reported the patient's discharge.

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

Resolution Tips for 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 whether 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 their MAC as soon as it is evident that a resolution cannot be reached. Requests received for claims past the timely filing limit will not be processed without good cause as defined in the Medicare Claims Processing Manual. 

Reference: CMS IOM Pub. 100-04 Medicare Claim Processing Manual, Chapter 1, Section 70.7

To request assistance with resolving a billing dispute, go to Request for Assistance (RFA) Documentation Support Form. Ensure all information is completed as incomplete requests will not be processed.

Requests will be processed within 45 calendar days of the date they are received. We will notify the provider of the outcome by letter. The MAC may request additional documentation including call logs, letters, or bill attempts, and supporting medical records including transfer agreements, admission orders, or discharge summaries.

Please select one of the topics below to view specific facility information. 

Resolution Tips for Inpatient Hospitals

Hospital transfer situation: Hospitals must 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 are also expected to submit discharge claims using the patient discharge status code that reflects the same-day admission to the subsequent facility. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 3, Section 20.1.2.4

Hospital discharge coding: Hospitals must ensure that the patient status code reported on the claim reflects the patient's discharge disposition for 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 will need to submit an adjustment bill to correct the patient discharge status code. 

Reference: MLN Matters Special Edition Article SE1411, Clarification of Patient Discharge Status Codes and Hospital Transfer Policies

Hospital overlapping with home health care: A patient cannot receive home health care while in an inpatient hospital stay. When the patient is in the hospital that falls within a 60-day episode of care, the HHA is required to omit those dates from their final (end of episode) claim. However, both the hospital and the HHA can be paid for the date of admission to the hospital stay. The HHA can also receive payment for services rendered to a patient on the date of discharge from an inpatient hospital stay. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 10, Section 30.9

Hospital overlapping with an LTCH: When a patient is admitted to an inpatient acute care hospital, upon discharge from a long-term care hospital (LTCH) and is readmitted to the same LTCH within three 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 diagnosis related group (DRG).

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 3, Section 150.9.1.2

Hospital overlapping with an IPF: When the stay is for three days or less, verify the inpatient psychiatric facility (IPF) has added occurrence span code (OSC) 74 with the associated dates of service. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 3, Section 190.7.1

Hospital overlapping with an IRF: When the stay is for three days or less, verify the inpatient rehabilitation facility (IRF) has added OSC 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. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, 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 three days preceding the date of the admission are not part of the payment window. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, 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 must ensure that the claim reflects the patient's admission and discharge dates. In addition, the patient discharge status code reported on the claim must correspond to the patient's discharge disposition. If the patient was transferred from a SNF and returned to the SNF prior to midnight, the hospital needs to bill a same day transfer. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, 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. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 3, Section 40.2.5

Same-day, same-provider acute care readmissions: 

  • If the patient is readmitted on the same day for symptoms related to prior admission, then the facility needs to combine the bills to create one continuous stay. The other facility must bill the hospital under arrangement.
  • If the patient is readmitted on the same day for symptoms not related to the prior admission, then two separate claims are required with the second claim having condition code (CC) B4. The other facility bills a same day transfer.

Resolution Tips for 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 must look to the inpatient facility for payment under arrangements. 

Reference: CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 6, Section 10 and Section 20.4.5

Hospital outpatient overlapping a SNF Part A stay: A patient may receive outpatient hospital care during a covered Part A SNF stay. Certain services may be part of SNF consolidated billing (CB), and therefore payment received for those services must be made by the SNF to the outpatient facility.

Reference: SNF Consolidated Billing 

Resolution Tips for SNFs

SNF transfer situations: SNFs must 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 must submit discharge claims using the patient discharge status code that reflects the patient's discharge disposition. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 6, Section 40.3.4

If the patient was admitted to the hospital and returned to the SNF prior to midnight, the SNF needs to submit a discharge claim and then submit a new claim with a new admit date. This would be considered a readmission, and the CC 57 needs reported on the claim. As a reminder, inpatient admission to a hospital or admission to another SNF forces a discharge from a SNF. 

Reference: CMS IOM Pub. 100-04 Medicare Claim Processing Manual, 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 HHA 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. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, 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 ensure that the patient discharge status code reported on the claim reflects the patient's return to the hospital.

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 6, Section 40.3.4

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 OPT, the SNF and the OPT must enter into an agreement where services will be paid to the SNF and the SNF will reimburse the OPT. Arrangement examples can be found on the CMS website under Best Practice Guidelines. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, 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. 

Reference: CMS IOM Pub.100-04 Medicare Claims Processing Manual, Chapter 3, Section 150.9.1.2

SNF consolidated billing: The consolidated billing (CB) requirement places billing responsibility on the SNF for the entire package of care that residents receive during a Part A SNF stay and for physical, occupational, and speech therapy services received during a non-covered stay. There are a limited number of services specifically excluded from CB, and therefore, separately payable. 

Reference: SNF Consolidated Billing 

Resolution Tips for ESRD Facilities

ESRD claims 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 CB. The ESRD facility can be paid for the date of admission to or discharge from an inpatient hospital. Dialysis services furnished during the inpatient stay are included in the hospital's responsibility for inpatient care. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 8, Section 10.5

Resolution Tips for HHAs

HHA transfer situations: Only the patient can elect to transfer from one HHA to another. 

When a patient has elected to transfer from one HHA to another, the receiving HHA is required to:

  1. Access the patient’s eligibility records in the direct data entry (DDE) system and print and save a copy of the page that validates whether the patient is under an established home health plan of care.
  2. Contact the transferring agency to arrange for a transfer date.
  3. Document the name of the individual with whom they communicate, the date and time of the contact and the date of transfer.
  4. Inform the patient that the initial HHA will no longer receive Medicare payment or provide services after the date of the elected transfer.
  5. Document in the patient’s file that he/she was notified of the transfer criteria and possible payment implications.
  6. Send a copy of the transfer agreement to the transferring agency.

The transferring agency is required to document the following:

  1. Date and time that the receiving HHA contacted them to inform them of the transfer.
  2. Name of the individual from the receiving agency.
  3. The date agreed upon for the transfer.
  4. Retain a copy of the transfer agreement.

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 10, Section 10.1.13 and 10.1.15

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 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. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 10, Section 30.9

Home health overlapping with CORF or OPT: 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 OPT, the HHA and the OPT must enter into an agreement where services will be paid to the HHA and the HHA will reimburse the OPT. 

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 negative pressure wound therapy (NPWT) using a disposable device is included in the Home Health Prospective Payment System (PPS) base payment rates. HHAs must provide the covered home health services, except durable medical equipment (DME), either directly or under arrangement, and must bill for such covered home health services. 

References:

Resolution Tips for CORFs and OPTs

CORF or OPT 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 a CORF or OPT, the SNF and the CORF or OPT must enter into an agreement where services will be paid to the SNF and the SNF will reimburse the CORF or OPT.

CORF or OPT 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 a CORF or OPT, the HHA and the CORF or OPT must enter into an agreement where services will be paid to the HHA and the HHA will reimburse the CORF or OPT. 

Reference:CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 7, Section 10.10

Resolution Tips for 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 CC 07. 

Reference: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, 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 the Social Security Administration to update the Hospice record.

Resolution Tips for Hospices

Hospice transfer situations: Hospices are expected to ensure they are verifying a patient’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 patient or authorized representative is required to ensure a transfer notice is on file with both hospices at the time of the transfer. Given that hospice patients are terminally ill and may not be able 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. 

Reference: CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 9, section 20.2.1

Hospice overlapping with other provider types: Hospices generally do not encounter overlapping situations with other provider types as hospice care may be provided in any location where the patient resides whether temporarily or permanently. Once enrolled in the hospice Medicare benefit, the hospice is responsible for managing the patient’s care related to the terminal illness. All services related to the terminal illness are billed to Medicare by the hospice agency. The hospice also coordinates with other providers for services not related to the terminal illness to support billing of non-related services.