SNFs: Missing Medicare Health Insurance Claim Number on Minimum Data Set Can Cause Potential Claim Denials

Our Medical Review department has noted many cases where the HIC number is missing from the MDS that is in the repository.

MDS Overview

The MDS is used to determine a patient's anticipated resource utilization and supports the clinical services provided as well as the SNF reimbursement rate. Each MDS represents the beneficiary’s clinical status based on an assessment reference date and established look back periods for the covered days associated with that MDS. Medicare covers SNF services at the rate based on the most recent clinical assessment (i.e., MDS), for all covered days associated with that MDS. Medical review decisions are based on documentation provided to support medical necessity of services recorded on the MDS for the claim period billed.   

Missing Information on MDS

When our Medical Review Department is unable to locate the MDS associated with a claim under review in the repository, your claim may be denied due to missing or incomplete documentation. Recently it has been noted that the beneficiary’s Medicare HIC number is often missing on the MDS that has been submitted to us. When this information is missing, it makes it difficult to locate the MDS in the repository. 

What You Should Do Now

To prevent unnecessary claim denials, make sure that all required fields are filled out on the MDS. Update any internal policies and procedures and most importantly, make sure all appropriate staff is aware of this information.   

Reviewed 5/9/2024