Skilled Nursing Facility: Not Covered by This Payer (Consolidated Billing Denials)

Published 04/09/2024

Denial Reason, Reason/Remark Code(s)

  • CO-109: Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
  • Codes: Multiple procedure codes, including CPT® code 36415

Resolution

  • Payment for many services provided to beneficiaries that are in a skilled nursing facility (SNF) is made to the SNF and not to the individual provider. This payment methodology is known as SNF consolidated billing.
  • SNF consolidated billing applies to patients that are in a covered Part A stay
  • In order to submit claims correctly and prevent overpayments, it is imperative that you know if your patient is a SNF resident in a Part A covered stay prior to submitting the claim. The best way to verify a patient's SNF status is to ask personnel at the SNF. The SNF will know if it is receiving payments from Medicare for that patient's care.
  • In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare covered SNF stay be included in a bundled prospective payment made through the fiscal intermediary/A/B MAC to the SNF. These bundled services had to be billed by the SNF to the FI/A/B MAC in a consolidated bill. No longer would entities that provided these services to beneficiaries in a SNF stay be able to bill separately for those services. Medicare beneficiaries can either be in a Part A covered SNF stay, which includes medical services as well as room and board, or they can be in a Part B non-covered SNF stay in which the Part A benefits are exhausted, but certain medical services are still covered though room and board is not.
  • There are exceptions to SNF consolidated billing. The best way to find out if your service is separately payable is to check the CMS SNF Consolidated Billing website. Go to the Carrier File Explanation link to read the background information.
  • Go to the Contractor Update for the year in which your service was provided to download coding files
    • If the service is an exception to SNF consolidated billing, it can be submitted to Palmetto GBA
    • If the service is not an exception to SNF consolidated billing, the Medicare payment for the service is included in the payment made to the SNF. Part B providers cannot be reimbursed separately for these services.
    • If you submit a claim to Palmetto GBA for a SNF resident and Palmetto GBA pays the claim, SNF consolidated billing may still apply. Claims may be paid in error when the Common Working File (CWF), which is a master eligibility file used by Medicare contractors, is not updated. One reason for delays in CWF updates is that SNFs may not file claims as quickly as Part B providers.

References


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