Awareness : Newsletter Articles

Exempt PPS Inpatient Provider Billing Guidelines

Providers that are inpatient children’s 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.