RESOLVED: SNF 21X TOB Adjusted in Error


Resolved: SNF 21X TOB Adjusted in Error

Current Status

Date

 

Resolved

May 25, 2021

This alert was for informational purposes only.

Update

May 25, 2021

Status: Palmetto GBA has inactivated adjustments if the adjustment suspended and were caught during claims processing. Adjustments that did not suspend reissued payment per the regular adjustment process and do not require further MAC action.

Provider Action: Providers need to resubmit a new claim, which will suspend for Palmetto GBA to manually process. 

Initial

May 17, 2021

Status: Palmetto GBA is inactivating adjustments if the adjustment suspended and were caught during claims processing. Adjustments that did not suspend reissued payment per the regular adjustment process and do not require further MAC action.

Provider Action: Providers need to resubmit a new claim, which will suspend for Palmetto GBA to manually process. 

 Date Identified

April 26, 2021

Issue:

Certain Skilled Nursing Facility (SNF) Interrupted Stay claims rejected incorrectly when there is a denied/rejected inpatient hospital stay. The Fiscal Intermediary Shared System (FISS) rejected 21X or 18X Types of Bill (TOBs) with reason code 38004 when there is an inpatient hospital claim with 110 TOB and outpatient claims with 12X and potentially a 13X with emergency room (ER) services submitted during an interrupted stay. Also, when the SNF claim processed prior to the hospital claims, 121x and 13X (Emergency Room (ER) services) TOBs received a line item reject code C7252. When the SNF claim processes after the 12x/13x claims, those outpatient claims received an Informational Unsolicited Response (IUR) that triggers an incorrect adjustment.

CMS instructed MACs to apply a claim level override of SNF CB edit 38004 for 21X and 18X when there is a TOB 110 present and a TOB 12X and/or 13X with (ER services) paid during an interrupted stay, as shown on the SNF claim by OSC 74. Also, to apply a claim level override if the claims come in with the TOB 110 TOB first and the hospital 12X and 13X (ER services) claims edit for C7252. Additionally, MACs will override edit 38004 on the SNF 21X or 18X TOB if this edit is received when the 12X/13X processes first receives C7252, or when the TOB 110 /12x/13x TOB is processed with DOS that are included in the SNF 74 OSC span plus one day.

 


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Last Updated: 07/30/2021