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Printed Date: 9/22/2015
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:
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.
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:
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.
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:
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.”
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.
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:
When a patient revokes hospice during an inpatient stay:
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:
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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Last Updated: 10/16/2019