CMS Pub. 100-04, ch. 30, § 130.3

Claims for Services Furnished in Noncertified or Inappropriately

Certified Beds

(Rev. 4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18)

A. General

Payment for SNF and hospital claims may not be denied solely on the basis of a

beneficiary’s placement in a non-certified portion of the same institution that also

includes a participating SNF or hospital. When requested by the beneficiary or his/her

authorized representative, a provider must submit a claim to the A/B MAC (A) for

services rendered in a non-certified bed. When the A/B MAC (A) reviews a claim for

services rendered in a non-certified bed, it first determines whether the beneficiary

consented to the placement. (See subsection C.) If the A/B MAC (A) finds that the

beneficiary consented, it denies the claim. If it finds that the beneficiary did not consent,

it determines whether there are any other reasons for denying the claim. (See subsection

D.) If there is another reason for denying the claim, the A/B MAC (A) denies it.

However, if none of the reasons for denial exist, beneficiary liability must be waived as

provided under §1879(e) of the Act and a further determination must be made as to

whether the provider, rather than the Medicare program, must accept liability for the

services in question. (See “Coverage of Extended Care Services Under Hospital

Insurance” in the Medicare Benefit Policy Manual, Chapter 8.)

B. Provider Notice Requirements

When a SNF or hospital places a patient in a noncertified or inappropriately certified

portion of the institution because it believes the patient does not require a covered level

of care, or for any other reason, it must notify the patient (or authorized representative) in

writing that services in a noncertified or inappropriately certified bed are not covered.

The provider uses the appropriate notice specified in §70 for SNFs or swing beds, §80 for

inpatient hospitals, to advise the beneficiary of its decision to place him/her in a

noncertified bed, using language such as:

We are placing you in a part of the institution that is not appropriately certified by

Medicare because (you do not require a level of care that will qualify as skilled

nursing care/or covered hospital services under Medicare)/(or state any other

reasons for the noncertified bed placement). Nonqualifying services furnished a

patient in a noncertified or inappropriately certified bed are not payable by

Medicare. However, you may request us to file a claim for Medicare benefits.

Based on this claim, Medicare will make a formal determination and advise

whether any benefits are payable to you.

(For related general billing requirements, see Chapter 1, §60 of this manual, or other

chapters specific to the benefit being billed: Chapter 3 for inpatient hospitals and swing

beds, Chapter 6 for swing bed PPS and inpatient SNFs, and Chapter 7 for outpatient

SNFs.)

C. Determining Beneficiary Consent

The CMS presumes that the beneficiary did not consent to being placed in a noncertified

bed. In order to rebut the presumption of lack of consent, the provider must indicate on

the bill the date it provided the beneficiary with an ABN notifying the beneficiary that the

accommodations would no longer be covered; and requested the beneficiary’s signed

acknowledgement (on the ABN) of having received such a statement. Moreover, in any

case in which a Medicare beneficiary gives his/her consent to placement in a noncertified

bed, the provider must, if requested by the A/B MAC (A) (contemplated only at an

appeal level of claim processing), submit a copy of the ABN signed by the beneficiary to

the A/B MAC (A), for a determination of the ABN’s validity. The ABN must be signed

by the beneficiary (provided he/she is competent to give such consent) or by the

beneficiary’s authorized representative. If the beneficiary or his/her authorized

representative refuses to sign the form, the provider may annotate the file to indicate it

presented the ABN to the beneficiary (or his/her authorized representative), but the

beneficiary refused to sign. As long as the provider’s ABN notifies the beneficiary of the

likely Medicare noncoverage, the beneficiary’s refusal to sign the ABN does not render it

invalid. (See §40.3.4.6.) If any of the above requirements is not met, the A/B MAC (A)

automatically determines the ABN is defective.

When the A/B MAC (A) receives a claim with an indication that the provider has

provided the beneficiary or his/her authorized representative, with an ABN, the A/B

MAC (A) denies the claim and notifies the beneficiary that §1879 limitation on liability

cannot be applied because of the beneficiary’s valid consent to be cared for in a

noncertified or inappropriately certified bed. If the A/B MAC (A) determines that the

ABN is not valid, the A/B MAC (A) processes the claim in accordance with §130.4.

If the beneficiary appeals the initial denial, the A/B MAC (A) obtains the ABN from the

provider and determines whether it is valid. If the A/B MAC (A) determines that the

ABN is invalid, it notifies the provider and the beneficiary that payment may be made to

the extent that all other requirements are met.

D. Determining Whether Other Requirements for Payment are Met

Denials still are appropriate for any of the following reasons. The A/B MAC (A) must

undertake the development needed to permit a determination as to whether:

• The patient did not receive or require otherwise covered hospital services or a

covered level of SNF care;

• The benefits are exhausted;

• The physician’s certification requirement is not met;

• There was no qualifying 3-day hospital stay (applicable to SNFs only); or

• Transfer from the hospital to the SNF was not made on a timely basis. (However,

if transfer to an institution which contains a participating SNF is made on a timely

basis, a claim cannot be denied solely on the grounds that the transfer requirement

is not met because the bed in which the beneficiary is placed is not a certified

SNF bed.)

The A/B MAC (A) denies cases falling within these categories under existing procedures.

Also, if the beneficiary receives care in a totally nonparticipating institution, denial on the

grounds that the beneficiary was not in a participating SNF or hospital is still appropriate.

130.4 - Determining Liability for Services Furnished in a Noncertified

SNF or Hospital Bed

(Rev .4001, Issued: 03-16-18, Effective: 06-19-18, Implementation: 06-19-18)

The A/B MAC (A) presumes that the provider properly notified the beneficiary of

noncoverage, and that the beneficiary assented, if the claim includes the proper indicators

of liability notification.

The following development occurs only if the beneficiary appeals the A/B MAC (A)’s

decision that the beneficiary may not have liability waived because the provider gave

him/her timely notice that Medicare would not cover the accommodation; and that he/she

consented to being placed in a noncertified bed.

A. Beneficiary Liability

If the A/B MAC (A) determines that the beneficiary did not consent to placement in a

noncertified portion of the same institution that also includes the participating facility

(see §130.3.C), and that no other basis for denial of the claim exists (see §130.3.D), it

finds the beneficiary not liable under §1879 of the Act.

B. Provider Liability

If the beneficiary is found not liable under §1879, liability may rest with the provider, or

with the program. Liability rests with the Medicare program, unless any of the following

conditions exist, in which case the provider is liable for the services.

The provider did not give timely written notice to the beneficiary of the implications

of receiving care in a noncertified or inappropriately certified bed as discussed in

§130.3.B;

The provider failed to provide the beneficiary with an appropriate ABN and/or did

not attempt to obtain a valid consent statement from the beneficiary. (See §130.3.C.);

or

The A/B MAC (A) determined from medical records in its claims files that it is clear

that the beneficiary required and received services equivalent to a covered level of

SNF care, or that constituted covered hospital services, and the provider had no

reasonable basis for placing the beneficiary in a noncertified bed. Following are

examples of situations in which it would be found that the provider did in fact have a

reasonable basis to place a beneficiary in a noncertified bed:

EXAMPLES:

• The A/B MAC (A), a QIO, or Utilization Review Committee had advised the

provider that the beneficiary did not require a covered level of SNF care or

covered hospital services preadmission/admission;

• The beneficiary’s attending physician specifically advised the provider (verified

by documentation in the medical record) that the beneficiary no longer required a

covered level of care or services; note that if covered care had previously existed,

effective July 1, 2005, notification under the expedited determination process

would be required (see §20);

• A beneficiary not requiring covered services had a change in his/her condition

that later required a covered level of care or services and the provider had no

certified bed available (of course, the SNF transfer requirement must be met, see

the Medicare Benefit Policy Manual, Chapter 8.); or

• The A/B MAC (A) has other sufficient evidence to determine that the provider

acted in good faith but inadvertently placed the beneficiary in a noncertified bed.