Claims Overlap FAQs

Q: What is an overlap?

A: An overlap is when an incorrect claim submitted by the same or a different provider is processed and posted to the Common Working File (CWF), resulting in claim overlap rejection(s) of subsequent claim(s). When more than one provider is involved, the providers must work together to resolve the error. Some overlapping claim examples include:

  • Same provider — dates of service overlap
  • Charges that should have been combined on one claim
  • Outpatient claim submitted before allowing time for inpatient claim(s) to finalize
  • Claims that should have been submitted in service date sequence
  • Different provider — dates of service overlap
  • Did not report a leave of absence on the claim
  • Services subject to consolidated billing
  • Incorrect patient status code was submitted

Q: Why is my claim overlapping another facility’s when my dates do not fall within their dates of service?

A: The facility with the claim for the earliest dates of service may have billed an incorrect patient discharge status code. Applying the correct patient status code will help assure that the facilities receive prompt and correct payment.

  • If your patient status code is incorrect, it can indicate a patient is still in your facility when, in fact, they were discharged and admitted to another facility. It is recommended that you submit an adjustment to update the patient status on your claim.
  • If the other facility has submitted an incorrect patient status code, it is recommended that you contact the other facility and ask them to update the patient status code on the claim.

Example: The claim indicates that the patient is still in your facility (patient status 30), but the patient was transferred to a Medicare certified Skilled Nursing Facility (SNF) (patient status 03).

Resource: CMS internet-only-manual (IOM), 100-04, Chapter 25 (PDF, 238 KB) 

Q: What steps can be taken to identify claims that overlap with another provider?

A: If you receive an overlap reason code, you can do one of the following:

  • Verify your claims submitted through direct data entry (DDE)
    • Option -1 (Inquiry Menu), then option -12 (Claims Summary), and key in the Medicare beneficiary identifier (MBI), your provider number, and press Enter
    • Review the list of claims submitted to identify those with identical dates of service, and validate they were submitted accurately
    • Verify eligibility for home health episodes and hospice election from ELGA and/or ELGH screens
  • Verify the Beneficiary/Eligibility tab submenu on the eServices secure provider online tool
    • Home health episode "start" and "end" date, and the servicing provider’s NPI
    • Hospice election effective and termination date, revocation code and the servicing provider’s NPI
    • NPI registry lookup enables you to search for the provider’s information
  • Verify additional eligibility information from the submenu on the interactive voice response (IVR)
    • Hospice effective and termination dates (if applicable), and the servicing provider’s ID
    • Home health effective and termination dates (if applicable), and the servicing provider’s ID
    • SNF effective and termination dates (if applicable), and the servicing provider’s ID 

Q: I have contacted the overlapping facility numerous times and have asked them to correct their claim, but the claim has not been corrected. What steps can be taken to get the other facility’s claim updated?

A: While providers/facilities are required and expected to work together to resolve a billing issue, providers may occasionally require assistance from the Medicare Administrator Contractor (MAC). In that case, Palmetto GBA will work with both providers/facilities for resolution. In addition, Palmetto GBA will work with other Medicare administrative contractors (MACs) when the overlapping claim is processed by another MAC. Complete and submit "Billing Dispute Resolution Request Form."

Q: I contacted the SNF and asked them to update the patient status on their claim, but they stated that the patient’s benefits are exhausted, and that they are not responsible for paying the services. What should I do?

A: You must determine if the services were provided during the covered period of the SNF Part A stay or after the benefits exhausted, since consolidated billing rules may or may not apply. The SNF is required to bill “benefits exhaust” and/or “no pay” claims until the patient is discharged from the facility. In order to bypass Medicare edits, refile your corrected claim after the SNF has submitted or corrected their claims. In addition, it is recommended that you work with the SNF to help determine if the patient’s services were provided during the covered or non-covered portion of the stay and for claims resolution since timely filing rules apply.

Scenarios:

  • Services were provided during the SNF covered Part A Stay
    • SNF consolidated billing rules apply
  • Services were provided after the benefits exhausted
    • SNF is only responsible for billing physical, occupational and speech therapy services
    • All other services may be billed directly to the Medicare administrative contractor (MAC)
  • Services were provided after the patient was discharged
    • All services may be billed directly to the MAC

Benefits Exhaust
The SNF is only responsible for billing physical, occupational, and speech therapy services received during a non-covered stay. The beneficiary’s non-covered stay may be due to Part A benefits being exhausted, post hospital stay or the beneficiary did not meet SNF level of care requirements.

SNF Consolidated Billing
The consolidated billing requirements confer on the SNF’s billing responsibility for the entire package of care a resident receives during a covered Part A SNF stay.

The SNF must submit Medicare claims for all services rendered to their residents under a covered Part A SNF stay, except for certain excluded/separately payable services.

Refer to the CMS SNF Consolidated Billing for a list of excluded/separately payable services:

  • [CCYY] Part A MAC Update - Downloads
  • [CCYY] Part B MAC Update - Downloads

The SNF must either furnish the service directly with their own resources or obtain the service from an outside entity (such as a supplier) under an “arrangement.”

  • Under such arrangement, the SNF must reimburse the outside entity for those Medicare covered services subject to consolidated billing
    • Refer to the CMS SNF PPS Best Practices Guidelines for sample agreements if you need to establish payment arrangements with the SNF

Note: Absence of a valid arrangement does not invalidate the SNF’s responsibility to reimburse suppliers for services included in the SNF stay.

Resources: CMS internet-only manuals (IOM) 100-04, Chapter 6 (PDF, 488 KB) and Chapter 1 (PDF, 4.24 MB), MLN Matters Article MM4292 (PDF, 91 KB)

Q: My inpatient claim is overlapping a home health episode with the same date(s) of service. How can I resolve this?

A: Claims for inpatient hospital and skilled nursing facility (SNF) services have priority over claims for home health services, as beneficiaries cannot receive home care while they are institutionalized. Beneficiaries cannot be institutionalized and receive home care simultaneously.

  • Verify dates of service on your claim
    • If dates of service are incorrect, correct your claim and resubmit
    • If dates of service are correct, it is recommended that you contact the home health agency and ask them to correct their claim
  • Edit exclusions:
    • The inpatient claim admission date is the same as the HHA transfer/discharge date
    • The inpatient claim discharge date is the same as the home health agency admission date
    • The inpatient claim dates are between the occurrence span code 74 "From" date and the day following the occurrence span code "Through" date

Resource: CMS IOM, 100-04, Chapter 10 (PDF, 749 KB), section 30.9, and Chapter 25 (PDF, 238 KB)

Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?

A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.

When a beneficiary elects hospice during an inpatient stay:

  • Bill traditional Medicare for period before hospice election
  • Patient status code is 51 (discharge to hospice medical facility)
  • Discharge date is the effective date of hospice election
  • Bill hospice for period of care after hospice election

When a patient revokes hospice during an inpatient stay:

  • Bill hospice for period up to hospice revocation
  • Bill traditional Medicare for period after hospice revocation
  • Admission date is same as the hospice revocation date
  • Statement from date is the same as the hospice revocation date

See C7010 Claim Submission Error Help article for more information.

Resources: CMS IOM 100-02, Chapter 9 (PDF, 640 KB)

Q: The claim for my patient’s dates of service overlaps a Medicare Advantage (MA) plan and hospice elections period. Should I bill the hospice, traditional Medicare, or the MA plan?

A: Federal regulations require that Medicare administrative contractors (MAC) maintain payment responsibility for managed care enrollees who elect hospice.

While a hospice election is in effect, certain types of claims may be submitted to the MAC by either the hospice provider or a provider treating an illness not related to the terminal condition. These claims are subject to the usual Medicare rules of payment, but only for the following services:

  • Hospice services covered under the Medicare hospice benefit are billed by the Medicare hospice
  • Institutional providers may submit claims to Medicare with the condition code “07” when services provided are not related to the treatment of the terminal condition
  • MA plan enrollees that elect hospice may revoke hospice election at any time, but claims will continue to be paid by the MAC as if the beneficiary were enrolled in Medicare until the first day of the month following when hospice election was revoked

Example:

Beneficiary’s hospice election period ended on 1/10/YY

Bill the MAC for claims for dates of service 1/11/YY to 1/31/YY

Bill the MA plan for claims for dates of service 2/1/YY and beyond

Resource: CMS IOM 100-04, Chapter 11 (PDF, 484 KB), section 30.4, 50

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