What is claim overlap ? Claim submitted for same DOS

Q: What is an overlap?

A: When an incorrect claim is processed and posted to the Common Working File (CWF), resulting in claim overlap rejection(s) of subsequent claim(s), submitted by the same or a different provider. 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 should be combined on one claim
• Outpatient claim submitted before allowing time for inpatient claim(s) to finalize
• Claims should be submitted in service date sequence
• Different provider – dates of service overlap
• Did not report a leave of absence on the claim
• Services are 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 the facility (patient status 30), but the patient was transferred to a Medicare certified Skilled Nursing Facility (patient status 03).

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 the billing issue, providers may occasionally require assistance from the Medicare Administrator Contractor (MAC). In that case, First Coast will work with both providers/facilities for resolution.

For further assistance with these claims, write in to the First Coast claims department: In order for your request to be considered, supporting documentation must be included with your written request to:
Medicare Part A
P.O. Box 2711
Jacksonville, FL 32231-0021


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


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 home health agency 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

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