Reason Code U5233

Description
The services on the claim fall within or overlap a Medicare Advantage (MA) plan enrollment period.

Resolution

  • Obtain the managed care plan information from the Direct Data Entry (DDE) system, the Interactive Voice Response (IVR), or the eServices Portal. Submit a claim to the managed care plan for payment.
  • For certain inpatient services, an informational-only claim must be submitted to Medicare for the purpose of tracking benefit utilization and, in some cases, for the provider to receive special payments. Informational-only claims are submitted as follows:

Acute
IRF
LTCH
CAH
SNF/SB
Non-teaching facility
Covered claim with condition code 04 for Disproportionate Share Hospital (DSH) payment
Covered claim with condition code 04 and the Case-Mix Group (CMG) code and assessment date from the IRF Patient Assessment Instrument (PAI) for Low-Income Patient (LIP) payment
Covered claim with condition code 04 for DSH payment
Covered claim with condition code 04 for Electronic Health Record (EHR) incentive payment
Submit claim to the managed care plan for payment; submit the same claim to Medicare to track benefit utilization
Teaching facility
Covered claim with condition codes 04 and 69 for DSH and Direct Graduate Medical Education (DGME) payments
Non-covered claim with condition codes 04 and 69 for LIP and DGME payments
Non-covered claim with condition codes 04 and 69 for DSH and DGME payments
Not applicable
Not applicable

Note: Managed care informational-only claims are not required for outpatient hospital or Inpatient Psychiatric Facility (IPF) services. If requesting a denial based on coverage by a managed care plan, submit the claim as covered without condition code 04 or 69.

If the beneficiary is enrolled in a managed care plan for only a portion of an inpatient stay, submit the claim as follows:

IPPS
IPF
IRF
LTCH
CAH
Non-IPPS
SNF/SB
  • If Medicare is primary upon admission, bill the entire claim to Medicare
  • If the managed care plan is primary upon admission, bill the entire claim to the managed care plan
  • Bill the managed care plan for days the patient is enrolled in the managed care plan
  • Bill Medicare for the days the patient is not enrolled in the managed care plan

Reference: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 1 (PDF, 1.61 MB), section 90.
  • If the beneficiary is enrolled in a managed care plan and elects the hospice benefit, all hospice and non-hospice related services beginning on the date of the hospice election are billed to Medicare as follows:
    • Hospice services covered under the Medicare hospice benefit are billed by the hospice provider to the home health and hospice (HHH) Medicare Administrative Contractor (MAC)
    • Services provided by the enrollee's attending physician (if the physician is not employed by or under contract to the enrollee's hospice) are billed by the physician to Part B of the A/B MAC
    • Services not related to the treatment of the terminal condition are billed by the provider to Part A of the A/B MAC with condition code 07
    • Services furnished after the revocation or expiration of the enrollee's hospice election are billed accordingly until the full monthly capitation payments begin again. Monthly capitation payments begin on the first day of the month after the beneficiary revokes the hospice election.

Reference: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 11 (PDF, 483 KB), section 30.4.

 

 

Contact Palmetto GBA JM Part HHH Medicare

Email HHH

Contact a specific JM HHH department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

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