US · guidance
CMS Pub. 100-04, ch. 3, § 100.10
Requirements for Processing Programs of All-Inclusive Care for
the Elderly (PACE) Disenrollments during an Inpatient Stays
(Rev. 12148; Issued: 07-21-23; Effective: 01-01-24; Implementation:01-02-24)
Medicare is precluded from making payment for services or items that are paid for
directly or indirectly by another government entity. For inpatient claims where the
PACE is the Payer, the covered PACE services are exclusions to the Medicare
program per Section 1862 of the Social Security Act. If the PACE doesn’t approve all
the services due to disenrollment from the program, any Medicare covered services
not considered by the PACE program may be billed to the Medicare program. The
provider should identify PACE in the group name and or the PACE taxonomy code
251T00000X in the group number.
When a PACE beneficiary is inpatient and has been disenrolled in PACE, the facility
shall use Condition Code 35 to indicate the patient is a PACE eligible patient that
has disenrolled during an inpatient stay and value code 42 with the amount of the
PACE payment for the authorized days during enrollment in the PACE program.
History
(Rev. 12148; Issued: 07-21-23; Effective: 01-01-24; Implementation:01-02-24)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
cabd2102fd3a3b6b4e697803e3ef6dc316294c3ab89cb628d021c206acee786c
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