CMS announces SNF claims hold

Nov 07, 2019
The Bottom Line

As CMS has undertaken the implementation of the Patient Driven Payment Model (PDPM), they are holding a limited number of SNF claims while they make further refinements to the claims processing system. PDPM was effective on October 1, 2019.

Specifically, CMS is holding claims with:

  • Dates of service October 1, 2019 or later and
  • Type of Bill (TOB) inpatient services (21X) and swing bed services (18X) subject to SNF Patient Driven Payment Model (PDPM) and
  • Multiple line items, Health Insurance Prospective Payment System (HIPPS) codes, with different rate codes (revenue code 0022).

Typically, SNFs bill these claims on monthly cycles. Claims with single HIPPS codes were previously being held but are now being released for processing. CMS states that it anticipates releasing the remaining held claims in late November, once it completes systems testing to ensure accurate and timely payment. As of November 1, less than 50 claims are being held.

In addition, CMS underpaid some SNF inpatient services (21X) and swing bed services (18X) claims for dates of service in October 2019 with a single line item, single HIPPS code. CMS is automatically reprocessing those claims; no provider action is needed.

CMS will continue to provide updates as further information develops.

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