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Reason Code: U5233

Error Description:

The services on this claim fall within or overlap an MA HMO enrollment period. For inpatient PPS claims, the admission date falls within the HMO enrollment period.

Avoiding/Correcting This Error

Verify the admission date, from, and through dates on the claim and compare the dates to the HMO entitlement dates.

  • Outpatient facilities and inpatient noninpatient PPS and IRF hospitals, or LTCH billing services within an HMO enrollment period must be submitted directly to the appropriate HMO contractor.
  • Non-PPS inpatient hospital or inpatient SNF services which overlap either the effective or termination date of the HMO period will need to be split. Submit services rendered during the HMO enrollment period to the appropriate HMO contractor. Submit services rendered outside of the HMO enrollment period to the MAC.
  • IPPS, IRF, and LTCH claims and covered SNF services during the HMO enrollment period should be submitted to the MAC in order to post an informational no-pay encounter claim. It is necessary for these days to be captured by the CMS in the DSH (or LIP for IRF) calculations and to take benefit days from the spell of illness on the CWF.
  • IPPS acute care teaching hospitals billing for IME payment must bill with both a condition code 04 and 69 and with covered charges.
  • Effective with discharges on or after 10/1/2006, non-teaching IPPS hospitals, IRFs and LTCHs are required to submit informational no-pay encounter bills. These nonteaching hospitals are required to submit claim with covered charges and a condition code 04. Effective July 2012, IRF providers must use an appropriate HIPPS code based on the PAI assessment accompanied by an occurrence code 50 and the corresponding assessment date when submitting no-pay claims.
  • Effective 1/1/2008, all SNF-covered services during an HMO enrollment period must be billed using condition code 04 with covered charges in order to post the no-pay encounter claim. No claim should be submitted to the MAC for noncovered SNF stays or for dates of service prior to 1/1/2008.