Health Information Management

Tip: Know which denials are subject to Part B rebilling ruling

APCs Insider, June 7, 2013

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CMS' ruling (CMS-1455-R) released March 13 (published in the Federal Register on March 18), allows full Part B payment for inpatient stays that had been denied as not reasonable and necessary.

The ruling only applies to Part A claims denied as not reasonable and necessary by a contractor:
  • After March 13
  • Prior to March 13, but the time frame for appeal has not expired
  • Prior to March 13 and an appeal is pending
The ruling applies to denials while the ruling is in effect. CMS simultaneously published a proposed rule that once finalized would limit some of the policies in the ruling, including the timely filing exception.
Providers should expedite their rebilling under this ruling if they have denials subject to the ruling for which the original date of service is more than one year ago. To avoid processing problems, however, providers should wait until at least the implementation date of the transmittal (July 1, 2013) or they receive instructions from their contractor that systems are ready to receive, process, and properly pay claims.
 
CMS does not plan to extend timely filing exceptions under the proposed rule on rebilling, but is considering expanding the policy to provider self-audit denials. This will emphasize the importance of provi­ders conducting utilization review even after discharge to ensure the correct Part of Medicare (A or B) is billed prior to timely filing expiring.
 
This tip is adapted from “CMS releases details on Part A to B rebilling” in the June issue of Briefings on APCs.



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