who would be responsible if patient enrolled in HMO for some period

Error Code               Description                  Common Resolutions

0453

Enrolled in HMO or an Encounter Claim for F. F. S.


Verify the enrollee eligibility and bill the claim to the appropriate carrier.


 Patient Is a Member of a Medicare Advantage (MA) Organization for Only a Portion of the Billing Period

Where a patient either enrolls or disenrolls in an MA organization (See Pub. 100-01, the General Information, Eligibility, and Entitlement Manual, Chapter 5, §80 for definition) during a period of services, two factors determine whether the MA organization is liable for the payment.

• Whether the provider is included in inpatient hospital or home health PPS, and

• The date of enrollment.


Q: How do I determine if a patient is enrolled in a Medicare Advantage (MA) plan, previously referred to as a Health Maintenance Organization (HMO)?

A: It is recommended you obtain eligibility and benefit information prior to rendering services to patients. Check Medicare website or IVR

You can also do the following:

• Ask patients if they have recently enrolled in any new health insurance plans.
• Request to see a copy of all of their health insurance cards.


Q: My patient enrolled in a Medicare Advantage (MA) plan during the middle of the inpatient hospital stay. Who should I bill?

A: When a patient enrolls or disenrolls in a MA plan during his/her inpatient stay, the following factors will determine whether to bill the MA plan and/or “traditional” Medicare:

1. The hospital provider receives prospective payment system (PPS) payments, or is exempt from PPS payments, or is a non-PPS provider; and

2. The date of enrollment/disenrollment with the MA plan


Inpatient PPS provider billing guidelines

The patient’s entitlement status at admission determines liability for inpatient acute care hospitals, inpatient rehabilitation facilities (IRFs), or long term care hospitals (LTCHs) that receive PPS payments.

If the patient was not enrolled in the MA plan at the time of admission and enrolls before discharge:

• Bill the entire inpatient stay to Medicare for payment
• MA organization is not responsible for payment
If the patient is enrolled in an MA plan at the time of admission and disenrolls before discharge:

• Bill the entire inpatient stay to MA plan for payment, and,
• Submit a no-pay claim to Medicare to report the patient’s inpatient utilization days

Exempt PPS inpatient provider billing guidelines

Providers that are inpatient children hospitals, cancer hospitals, and psychiatric hospitals/units exempt from PPS must split bill the appropriate coverage portion of the patient’s inpatient stay with Medicare and MA plan.

Example:
The patient is admitted on September 28 and discharged October 13, and enrolls in an MA plan effective October 1. Split bill as follows:

• Bill Medicare for dates of service September 28 through September 30; and,

• Bill MA plan for dates of service October 1 through October 13, and include necessary supporting documents; and

• Submit a no-pay claim to Medicare for dates of service October 1 through October 13 to report the patient’s inpatient utilization days

Non-PPS inpatient provider billing guidelines

Inpatient hospitals that do not receive PPS payments must also split bill and may only bill the MA plan for dates of service that fall within the coverage period enrollment and disenrollment dates.

Hospital Services

If the provider is an inpatient acute care hospital, inpatient rehabilitation facility or a long term care hospital, and the patient changes MA status during an inpatient stay for an inpatient institution, the patient’s status at admission or start of care determines liability.

If the hospital inpatient was not an MA enrollee upon admission but enrolls before discharge, the MA organization is not responsible for payment.

For hospitals exempt from PPS (children’s hospitals, cancer hospitals, and psychiatric hospitals/units) and Maryland waiver hospitals, if the MA organization has processing jurisdiction for the MA involved portion of the bill, it will direct the provider to split the bill and send the appropriate portions to the appropriate FI or MA organization. When forwarding a bill to an MA organization, the provider must also submit the necessary supporting documents.

If the provider is not a PPS provider, the MA organization is responsible for payment for services on and after the day of enrollment up through the day that disenrollment is effective.


Home Health

If the patient was enrolled in the MA organization before start of care, the MA organization is liable until disenrollment. Upon disenrollment, an episode must be opened under home heath PPS for billing to the FI.

If the beneficiary was not an MA enrollee upon admission but enrolls before discharge, the home health PPS episode will end as of the day before the MA enrollment. The episode will be proportionately paid according to its shortened length (i.e., paid a partial episode payment [PEP] adjustment). The MA organization is responsible for payment as of the MA enrollment date.

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