Sunday, May 15, 2016

Rejection code U5223,GHO paid prior. Patient enrolled in Medicare replacement plan.

We are receiving reject reason code U5233. What steps can we take to avoid this reason code?

A: You are receiving this reason code which indicates the admission date falls within a risk Group Health Organization (GHO) paid period (aka Medicare Advantage (MA) plan). The beneficiary was/is enrolled in a Medicare replacement plan for the date of service(s) billed and the claim should be filed to that plan for payment
Many times a claim will overlap a GHO period because it was open at the time of billing, but was subsequently closed by the time the provider researches the reason for rejection. The best way to avoid this reason code is to verify the beneficiary has traditional Medicare right before submitting the claim.

There are several ways to obtain beneficiary eligibility to determine if in a GHO:
1. Users can access eligibility information via direct data entry (DDE) pdf file.
2. Contact the interactive voice response (IVR) pdf file system by calling (877) 602-8816.
• Note: Customer service representatives cannot assist you with eligibility information and are required, by the Centers for Medicare & Medicaid Services (CMS), to refer you to the IVR.
3. 270/271 eligibility transactions external link-- you can obtain eligibility information in a batch format for a number of beneficiaries.
4. Confirm the beneficiary’s eligibility via the SPOT (Secure Provider Online Tool).
5. Upon admission for Medicare covered services, review all insurance card(s) the beneficiary may hold and verify the information on the card with the patient or their legal representative and determine if all the information is still valid.

Additionally, Centers for Medicare & Medicaid Services (CMS) requires providers to submit no pay claims to the Medicare administrator contractors (MACs) to report the patient’s MA inpatient days, and bill certain inpatient claims for reimbursement through the Part A cost report. The MACs reimburse for disproportionate share hospital (DSH), indirect medical education (IME), direct graduate medical education (DGME), and nursing allied health (N&AH). This type of duplicate billing is often referred to as “shadow billing”, since claims are submitted to both the MA plan for payment and MAC as “no pay” or “information only” billing.

IPPS hospitals with disproportionate share of low-income patients
If a hospital meets the disproportionate share hospital (DSH) definition, an additional operating cost payment will be made.
Inpatient prospective payment system (IPPS) hospitals and inpatient rehabilitation facility (IRF) hospitals/units are required to submit informational only bills for purposes of capturing the MA patients inpatient days for inclusion in the Supplemental Security Income (SSI) ratio. This ratio is used in the DSH and low income patient (LIP) for the IRF’s PPS calculations. This also applies to long-term care hospitals (LTCHs) even though they do not directly receive DSH, as an estimate of what the facility would have received under DSH if they were an acute care facility becomes part of the LTCH outlier calculation.

Claim submission guidelines are as follows:
• Type of bill = 11X
• Condition code 04
• Covered days and charges
• Revenue code 0024 containing CMG (case-mix groups) A9999 and include the discharge date in the service date field (only required by IRFs)
Approved teaching IPPS hospitals indirect medical education (IME)
Approved teaching hospitals submit informational only bills for IME payment. The purpose is to capture the MA patients inpatient days for inclusion in the SSI ratio and the provider statistics & reimbursement report (PS&R) type 118.

Claim submission guidelines are as follows:
• Type of bill = 11X
• Condition code 04 and 69
• Covered days and charges
Hospitals and units excluded from IPPS for DGME and N&AH education

Non-IPPS hospitals and units submit their MA claims to their respective MACs to be processed as no-pay bills, so the inpatient days can be reported on the patient’s record and PS&R type 118 for DGME payment purposes through the cost report. This applies to the rehabilitation, psychiatric, long-term care, children’s and cancer hospitals, plus rehabilitation and psychiatric units.

Claim submission guidelines are as follows:
• Type of bill = 11X
• Non-covered days and charges
• Condition code 04 and 69
Skilled nursing facilities (SNFs) and swing bed units
SNF providers must submit bills for beneficiaries enrolled in MA plans and receiving skilled care in order to take benefit days from the beneficiary and/or update the beneficiary’s spell of illness in the Medicare’s common working file (CWF) system.
Claim submission guidelines are as follows:
• Type of bill = 21X or 18X
• Covered days and charges
• Condition Code 04

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