Industry Insights

SNF Medicare Advantage Billing Requirements Changing This July

May 2014
Author:  Julie Bilyeu

Julie Bilyeu

Managing Director


Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)


Requirements for Medicare Advantage plans may change the way skilled nursing facility (SNF) providers currently bill claims.

Medicare Advantage (MA) refers to private insurance plans with which beneficiaries can choose to enroll as a substitution to original Medicare. The Centers for Medicare & Medicaid Services (CMS) will require MA plans to transmit health insurance prospective payment system (HIPPS) codes for all SNF claims effective with July 1, 2014, dates of service. Many MA plans already require providers to submit this information when billing claims; however, now those MA plans that are contracted with providers to reimburse based on level of care or per diem also will require this information. This change initially was slated for 2013 and was delayed multiple times before being pushed to the current July 1, 2014, transition date.

To determine the HIPPS code, providers must complete minimum data set (MDS) assessments in compliance with Medicare guidelines. The HIPPS code and assessment reference date (ARD) generated from the MDS will need to be included on claims, much like Medicare Part A billing requirements. Billing instructions can be found in Chapter 6 of the CMS Medicare Claims Processing Manual as well as Chapters 2 and 6 of the CMS Resident Assessment Instrument manual. However, be aware that MA assessments are not submitted to the federal repository like Part A assessments.

CMS has provided limited information on this change, as it expects communication to come directly from MA plans to providers. Based on communications received to date, MA plans may now require providers to meet both their contracted billing requirements and the new HIPPS code billing requirement. This means claims may need to accommodate revenue codes for both level of care and HIPPS codes. 

Billing Requirements

  • Contracted plans may still require revenue codes for level of care, i.e., 0192.
  • Claims must contain revenue code 0022 and correlating HIPPS codes for all applicable assessments.
  • Claims must contain occurrence code 50 and corresponding ARD dates for each HIPPS code billed.

If providers have not yet received communication from MA plans with which they are contracted, they should contact the plans to discuss billing requirements for July 1 service dates. 

Facilities that don’t currently complete assessments for MA payors should start tracking and completing assessments for all MA patients. For all MA patients who have assessments with payment windows covering July 1, assessments will need to be completed and the corresponding HIPPS codes entered on claims. Providers need to plan ahead, as this could include residents with admissions as early as March 24, 2014.

What You Need to Know

  • Effective with July 1, 2014, service dates, all MA claims need to contain HIPPS codes.
  • Instructions regarding specific billing requirements should be communicated to you by your MA payors.
  • Contact your software vendor about setting up your billing system to comply with these changes.
  • Plan now to complete MDS assessments for all MA residents.

If you have additional questions about how these changes could affect your organization, contact your BKD advisor.

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