Medical Billing Forum

Billing => Billing => Topic started by: ahall on September 22, 2015, 09:06:59 AM

Title: what goes on a no pay claim to medicare on UB
Post by: ahall on September 22, 2015, 09:06:59 AM
Need help.  I have not done a no pay claim to medicare before.  Work in a snf facility and a resident wants us to bill medicare first to get a denial so that his insurance will pay.  The resident did not have a qualifying stay at a hospital.  I know I need to use condition code 21 but what goes on the rest of the claim like revenue code, hcpcs, occurrence, value codes, etc.  A sample of one would be great to look at.  Thank you.
Title: Re: what goes on a no pay claim to medicare on UB
Post by: Michele on September 22, 2015, 09:32:04 AM
You would use the same Rev codes, hcpcs, etc that you use for a qualified stay.  Is it not a qualifying stay because the patient used up their benefit or because it is not for rehab, or what?  Whatever is the reason should be indicated either by diagnosis, or by the fact that Medicare already paid for their benefit so they will deny the claim.
Title: Re: what goes on a no pay claim to medicare on UB
Post by: ahall on September 22, 2015, 09:59:18 AM
Thank you.  No the resident didn't have a 3 midnight stay and has not used any medicare days,  so do I use the non-therapy rug level or do I use AAA with 00?
Title: Re: what goes on a no pay claim to medicare on UB
Post by: Michele on September 22, 2015, 10:14:26 AM
I got this from a Part A MAC website:

"Submitting Inpatient Part A No Pay Bills

In order to expedite the processing of inpatient Part A no pay bill(s); please follow the guidelines below:

    Use a condition code 20 when the beneficiary has requested a demand bill. (SNF's only)
    Use a condition code 21 when you have determined the patient is no longer receiving a skilled level of care or the service is excluded from Medicare coverage and you need a denial from Medicare in order to bill another insurance.
    Prior to Admit Date of October 1, 2006 if you are submitting the no pay bill due to the Medicare benefits exhausted, no qualifying hospital stay or the thirty day transfer requirement was not met, please enter verbatim the following remarks on page 4 of your claim:
    - "Benefits exhau" for benefits exhausted
    -" No QHS" (for no qualifying hospital stay, this applies to SNF's only)
    - "No 30 day tran" (for no 30 day transfer, this applies to SNF's only)
    If the claim does not have any of the criteria indicated above, it will be returned to you, (RTP'd)."

But I don't think this contains the answer to your question completely.  I haven't billed this out specifically so I'm not sure what the AAA 0 is.  I would submit the bill with the rev codes indicating the services provided, using the 21 condition code to indicate that it's not a covered Medicare expense.  I would think that would initiate a denial.