Long-Term Care Hospital

Long-Term Care Hospitals: How to Request Adjustments of Claims Paid at the Site Neutral Rate

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Long-Term Care Hospitals: How to Request Adjustments of Claims Paid at the Site Neutral Rate

Our Appeals Department has been inappropriately receiving appeal requests from LTCHs for inpatient claims paid at the site neutral rate asking for the claims to be paid at the standard LTCH PPS rate. LTCHs should not submit such appeal requests directly to our Appeals Department. To learn how to request payment for inpatient LTCH claims at the standard LTCH PPS rate which we paid at the site neutral rate, please review the information and instructions below.

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Background: Standard Payment vs. Site Neutral Payment

Prior to the PHE, we paid LTCHs for payable inpatient claims at the site neutral rate or at the standard LTCH PPS rate in two situations. During the PHE, we paid LTCHs for payable inpatient claims at the standard LTCH PPS rate even if such claims were only qualified for payment at the site neutral rate.

With the end of the PHE on 5/11/2023, we, once again, pay LTCHs for payable inpatient claims at the site neutral rate or at the standard LTCH PPS rate in two situations. Thus, as of 5/12/2023, we pay an LTCH:

  • Site neutral payment on payable inpatient claims in all but the below two situations.
  • Standard LTCH PPS payment on payable inpatient claims in the below two situations:
  1. The beneficiary was admitted directly to the LTCH from an IPPS hospital at which he/she spent at least three nights in an ICU or a CCU and the LTCH discharge is not assigned to a psychiatric or rehabilitation medical/surgical long-term care diagnosis-related group (MS-LTC DRG), OR
  2. The beneficiary was admitted directly to the LTCH from an IPPS hospital, the LTCH discharge includes the ICD-10-PCS procedure code for ventilator services of at least 96 hours (5A1955Z) and the LTCH discharge is not assigned to a psychiatric or rehabilitation MS-LTC-DRG.

To determine if we can pay an LTCH’s claim at the standard LTCH PPS rate in situations 1 and 2, we must review the preceding IPPS hospital’s inpatient claim. If that claim is not in our records, we must pay the LTCH’s claim at the site neutral rate. The IPPS hospital’s claim may not be in our records because they did not submit it to Medicare. This can occur for a variety of reasons which include, but are not limited to:

  • The beneficiary did not have Medicare at that time.
  • The beneficiary used VA benefits rather than Medicare.
  • The beneficiary used primary insurance per the MSP provisions and that insurance paid the services in full.

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Asking Your Medicare Administrative Contractor to Adjust LTCH Claims Paid at the Site Neutral Rate

To ask us to adjust an LTCH claim we paid at the site neutral rate and to pay it at the standard LTCH PPS rate:

  • Contact our PCC
  • Ask a PCC representative to send a claim adjustment request to our Appeals Department
  • Provide the PCC with information and/or documentation to support the request including the:   
    • Beneficiary’s last name and Medicare number
    • Inpatient LTCH claim’s DOS and DCN
    • Reason(s) the claim should be adjusted and paid at the standard LTCH PPS rate (e.g., there is a preceding IPPS hospital stay but the claim for the stay is not in Medicare’s records)
    • Information about the IPPS hospital’s claim (hospital’s name, DOS, number of nights in that hospital’s ICU or CCU, if applicable, and why that claim is not in Medicare’s records, if known).
    • Documentation that supports the preceding IPPS hospital stay (admission records/notes, phone calls to the hospital, or any record that indicates where the beneficiary was an inpatient prior to admission at your LTCH).

From the date you call our PCC, you will have three days to fax them the information and/or documentation. The PCC will determine if the information and/or documentation you provide is accurate and complete.

  • If it is, they will forward it to our Appeals Department.
  • If it is not, they will contact you. Note: If you advise the PCC you tried to obtain the documentation from the preceding IPPS hospital but you have not received it and you need our assistance, they will ask you for the details about your attempts and then ask our PRRS to assist you in obtaining that documentation.

Our Appeals Department has 60 days to review the information and/or documentation and adjust your claim.

  • If they adjust the claim and pay it at the standard LTCH PPS rate, you will see this on your RA.
  • If they do not adjust the claim, you will receive a call back from the PCC explaining the reason(s).

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Posted 1/12/2024