Hospital

Hospital Billing for Beneficiaries Enrolled in Option Code C Medicare Advantage Organization Plans 

A Medicare beneficiary can choose to enroll in an option code C MAO plan. If they do, that plan replaces their original Medicare. Original Medicare is not secondary to the MAO plan because the beneficiary is not enrolled in both. You can check if a beneficiary is enrolled in an option code C MAO plan using NGSConnex and/or HIPAA Eligibility Transaction System (HETS).

If you render outpatient or inpatient hospital services to a beneficiary who is enrolled in an option code C MAO plan at the time of services, submit a claim for those services to that MAO plan. Do not submit a claim to us instead as we will reject it based on the beneficiary’s MAO plan enrollment. 

Beneficiary Is Enrolled in an MAO Plan for a Portion of an Inpatient Hospital Stay

In most situations, the MAO plan is in effect during a beneficiary’s entire inpatient hospital stay. Because an inpatient hospital stay can span multiple dates, you may determine an MAO plan was in effect for only a portion of that stay. If this is the case, you must determine which payer is responsible for the inpatient stay – the option code C MAO plan, original Medicare or a combination of both. Refer to your hospital type below to determine the responsible payer(s):

  • PPS hospitals – ACHs, IPFs, IRFs and LTCHs: The beneficiary’s enrollment status (in original Medicare or an MAO plan) at the time of inpatient admission to your hospital determines liability for the inpatient stay. 
    • If a beneficiary is enrolled in original Medicare at admission, submit a claim for the inpatient stay to us, even if the beneficiary’s enrollment in an MAO plan (and disenrollment from original Medicare) becomes effective during that stay. 
    • If a beneficiary is enrolled in an MAO plan at admission, submit a claim for the inpatient stay to the MAO plan, even if the beneficiary’s disenrollment from that MAO plan (and enrollment in original Medicare) becomes effective during that stay. 
  • Non-PPS hospitals – cancer hospitals, children’s hospitals, CAHs: The beneficiary’s enrollment status (in original Medicare or an MAO plan) at the time of the actual services in your hospital determines liability for the days within the inpatient stay. Therefore, split the inpatient stay and submit separate claims; a claim to us for our portion of the stay and a claim to the MAO plan for its portion of the stay. 
    • Example: 
      • A beneficiary 
        • Was admitted to a cancer hospital on 8/25 and was enrolled in original Medicare on the day of the admission
        • Enrolled in an MAO plan which became effective on 9/1
        • Was discharged from the cancer hospital on 9/5
      • The cancer hospital 
        • Submits a claim to original Medicare for 8/25-8/31
        • Submits a claim to the MAO plan for 9/1-9/5

Original Medicare Requires Inpatient Hospital Claims for MAO Plan Enrollees

Teaching hospitals (all types), hospitals with only an approved N&AH program, non-teaching hospitals (except IPFs) and CAHs are required to submit an inpatient claim to us in addition to the option code C MAO plan for a beneficiary enrolled in that plan, whether the beneficiary was enrolled in the MAO plan during their entire inpatient stay or for only a portion of it. We refer to these additional inpatient hospital claims as informational, tracking, no-payment or shadow claims and you are required to submit them to us for one or more of the following reasons:

  • Tracking the beneficiary’s inpatient Medicare benefit period
  • Payment of DGME or IME to teaching hospitals when the claim processes or through the cost report
  • Payment of N&AH to hospitals with an approved N&AH program through the cost report 
  • Making DSH payments or LIP adjustments 
  • Electronic health records 

Note: You are not submitting these claims to receive an MSP payment.  

Hospital Billing – General Guidelines

Submit inpatient claims to us after you submit them to the MAO plan but within our one-year timely filing timeframe. You should do so even if the MAO plan did not pay the claim for any reason other than the beneficiary was not enrolled in their plan.  When preparing the inpatient claim, report: 

  • Original Medicare as the payer (do not report the MAO plan and do not code as MSP claim)
  • Beneficiary’s MBI (obtain from beneficiary)
  • All the usual claim requirements for the services (IRFs must report actual HIPPS code)
  • The TOB, covered or noncovered days/charges and the condition code(s) (CC) 04 and/or 69 or per the instructions in the Hospital Billing Table below
    • CC Definitions:
    • CC 04 = MAO plan enrollee
    • CC 69 = Billing for medical education (IME, DGME or N&AH)

Hospital Billing Table

Hospital Type TOB Days and Charges CC(s) Reason Code Payment
ACHs - Teaching Covered 111 Covered 04, 69 37210 IME through claim
Hospitals other than ACHs - Teaching Covered 111 Covered 04, 69 37574 DGME through cost report
ACHs with approved N&AH program Non-covered 110 Non-covered 04, 69 79995 N&AH through cost report
Hospitals other than ACHs with approved N&AH program Non-covered 110 Non-covered 04, 69 39934 N&AH through cost report
Hospitals (ACHs, IRFs and LTCHs) - Non-Teaching Covered 111 Covered 04 3719C Not applicable 
CAHs Covered 111 Covered 04 3719C Not applicable 

 

If you are required to submit inpatient claims to us after the MAO plan and you do so incorrectly, we reject the claims with reason code U5233 and you will need to resubmit correctly coded claims.  

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Posted 11/15/2024