Oct-Nov 00 Part A Bulletin - Medicare

SKILLED NURSING FACILITIES
Payment of Skilled Nursing Facility (SNF) Claims for Beneficiaries
Disenrolling from Terminating Medicare+Choice (M+C) Plans Who Have Not
Met the 3-Day Hospital Stay Requirement
Starting October 1, 2000, fiscal intermediaries are
implementing a manual mechanism to pay for claims
involving SNF care for beneficiaries involuntarily
disenrolling from M+C plans as a result of a M+C plan
termination when the beneficiary does not have a 3-day
prospective payment system hospital stay before SNF
admission. This manual mechanism will end December 31,
2000, with the implementation of the automatization of the
systems changes indicated in this article.
Policy Overview
Medicare will cover SNF care for beneficiaries
involuntarily disenrolling from M+C plans as a result of a
M+C plan termination when the beneficiary does not have a
3-day prospective payment system hospital stay before SNF
admission. If Medicare does not cover these claims,
beneficiaries will be liable for payment. Beneficiaries in this
situation have not been aware of their potential financial
liability for their SNF care.
Fiscal intermediaries (FIs) will start counting the 100
days of SNF care with the SNF admission date (regardless of
whether the beneficiary met the skilled level of care
requirements on that date). All other original Medicare rules
apply, such as the requirement that beneficiaries meet the
skilled level of care requirement (for the period for which
the original Medicare fee-for-service program is being
billed).
To pay SNF claims for enrollees without a 3-day
hospital stay and who are disenrolling from terminating
M+C plans, the 3-day hospitalization met requirement will
be deemed.
This policy is effective for services furnished on or
after January 1, 2000.
Billing Instructions
To be reimbursed for these bills skilled nursing facilities
must follow these billing instructions:
• Effective October 1, 2000, through December 31, 2000,
SNFs may submit a hardcopy claim with a note
indicating that condition code 58 applies to this claim.
Condition code 58 will be used in the future when the
beneficiary has been involuntarily disenrolled from a
M+C organization while in a SNF stay and when the 3day
stay requirement has not been met.
Effective January 1, 2001,
• Providers must use condition code 58 on the first feefor-service
(also known as “Original Medicare”) claim
for a beneficiary who was in a terminating M+C plan,
and was an inpatient of a SNF at the time of
termination.
• The beneficiary must be assigned to a resource
utilization group (RUG). Original Medicare coverage
rules regarding the skilled level of care requirements
will be applied. Payment will be made only for claims
submitted for beneficiaries in certified SNF beds.
Original Medicare fee-for-service rules regarding
beneficiary cost sharing apply to these cases. That is,
providers may only charge beneficiaries for SNF
coinsurance amounts. �
16 The Florida Medicare A Bulletin
October/November 2000