Claims - Skilled Nursing Facilities

Bill All Services

All incurred services, including those rolled up in the per diem eligible charge, should be billed on the UB-04 form. You must include the appropriate CPT or HCPCS code when billing for services payable outside of the per diem for all commercial plans.

Revenue Codes Versus CPT Codes

SNF providers must be able to distinguish between revenue codes and CPT codes when billing for outpatient services. Revenue codes identify a specific accommodation, ancillary service or billing calculation, and are derived from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual. CPT codes, issued by the American Medical Association, are part of a coding structure for medical procedures.

CPT Modifier Codes

When physical, speech or occupational therapy is provided in an outpatient setting, enter the appropriate two-character CPT modifier code in form locator 44 as follows:

Excluded Services

In situations where an SNF contracts with a pharmacy to provide medication to their SNF patients where the drugs are NOT included / EXCLUDED from the SNF per diem (e.g., IV medication etc.), these drugs are billed based on the agreement between the SNF and the pharmacy, and either the SNF or the pharmacy will bill HMSA for the drugs EXCLUDED from the SNF per diem for PB members, and HMSA will make payment to the provider who billed for the services.

Exhaustion of Medicare Benefits and No 3-Day Qualifying Stay Situations

When a Medicare patient's Part A benefits are exhausted, or the patient did not meet the Medicare coverage criteria (assuming that Medicare is primary and HMSA is secondary), submit claims to Medicare for Part B services. Refer to the Exhaustion of Medicare Benefits section of Coordination of Benefits with Medicare for more information. Claims for Part B services processed by Medicare should automatically cross over to HMSA for secondary payment. If your claims do not cross over, please contact us. When you submit claims for Part A services that are not eligible for Medicare payment directly to HMSA, please include a brief cover letter explaining the situation and write “Attention Claims Supervisor” on the envelope and on the cover letter. Please wait until the part B benefits have been paid before submitting claims for the Part A services to HMSA.

Note: When Medicare is primary, you must wait 30 days from the date of the Explanation of Medicare Benefits before submitting secondary claims to HMSA. For more information please refer to the letter we sent at Medicare Primary Claims Letter Sample [PDF].

Beginning March 1, 2020, we will require providers to include Medicare Parts A and B remittances with secondary skilled nursing facility claims submitted to HMSA for members with primary Medicare coverage and secondary HMSA coverage. This will ensure accurate coordination of benefits under the HMSA plan. The Medicare remittances must be included even when patients have exhausted their Medicare benefits or otherwise do not qualify for Part A benefits. As a reminder, the Medicare Claims Processing Manual requires skilled nursing facilities to submit bills for Medicare beneficiaries for every month of a stay even though no benefits may be payable. For more information please refer to Chapter 6 section 40.8 of the Medicare Claims Processing Manual.

HMSA Akamai Advantage® D-SNPs only

Beginning January 1, 2025, Dual Special Needs Plans (D-SNPs) covers additional SNF days up to 180 days.

Billing Guidelines

Prior to Medicare Part A SNF Benefit Exhaust:

• The SNF should follow their regular monthly claims submission procedures (e.g., bill monthly claims that include room & board and all ancillary services, etc.).

After Medicare Part A SNF Exhaust: 

• The SNF should split the Part A SNF covered services (days up to 100) from the additional SNF days (days 101 – 180).
• Days up to 100 should follow regular monthly claims submission procedures (e.g., bill monthly claims that include room & board and all ancillary services, etc.).
• Days 101 to 180:
  • Continue to submit monthly bills under the appropriate covered type of bill (i.e., TOB 21X).
    • Fully — Patient had no Part A benefit days available between the From and Through dates on the claim.
    • Partially — Patient had Part A benefit days available between the From and Through dates on the claim.
  • Bill A3 in Form Locator 31 and date when Part A SNF benefit is exhausted.
  • Report additional days (days 101 – 180) on a separate service line from pre-exhaust services and include modifier -KX on the line.
    • Continue to report revenue code 0022 and the applicable SNF PPS HIPPS code for additional SNF days.

NOTES:

Do not submit Part B services separately from the Part A SNF benefit exhaust claim. These services are included in the payment of the SNF exhaust claim.
The KX modifier does not bypass prior authorization requirements.

SNF Wait-Listed

When a patient is in a hospital inpatient acute setting waiting for an SNF bed, enter code 75 (SNF level of care) in form locator 35 of the UB-04, along with the dates that the patient is wait-listed in the occurrence span. The inpatient acute stay is paid according to DRG rates.

Intermediate Care Facility (ICF)

Intermediate Care Facility (ICF) beds are not covered by HMSA commercial plans.  When the patient is at the ICF level of care, include occurrence code 74 (non-covered level of care) in form locator 35 along with the date span involved if you are billing for an entire month.

HMSA Akamai Advantage® only: If you are submitting claims for a partial month of covered services when the member drops to the ICF level of care, you may submit a claim with:

• occurrence code 22.
• the date the patient dropped to the ICF level of care.
• patient status code 30 to indicate that the patient is still within the facility.

Please remember that if you bill a continuing type of bill (212 or 213) and the member drops level of care, you must submit either a discharge claim, or a claim for the entire period the member was at the ICF level before we will make payment for future services at the SNF level of care.

Claims Filing Errors

1. Form Locators 13 and 16: Use military time when indicating admit and discharge hours.
2. Form Locators 35 – 36: Occurrence span codes and dates should be completed from left to right and then from top to bottom. Form locators 35a and 36a should be completed before 35b and 36b. Also, make sure that billed units match the date spans indicated with occurrence code 50 on claims for HMSA Akamai Advantage members.
3. Form Locator 78 – 79: Claims for HMO members require that the referring provider be listed in form locator 78 or 79.
4. If your original claim was rejected by letter (Form 97) and not on an HMSA Report to Provider, do not follow claim resubmission guidelines.  Make any necessary corrections and submit the claim again with the appropriate type of bill. Claim resubmission guidelines should only be followed if your original claim was processed on an HMSA Report to Provider and assigned a claim ID for your reference.
5. Do not bill a separate RUG code for rehabilitation therapy assessments when the patient is at the skilled level of care.
6. When billing non-covered days for HMSA Akamai Advantage members, do not use assessment RUG codes.  Use the default code AAA00 for service dates prior to 11/1/2019, and ZZZZZ for service dates on or after 11/1/2019. 
7. If rehabilitation RUG codes are billed for HMSA Akamai Advantage members and no rehabilitation therapy ancillary revenue codes are included on the claim, the claims will be denied unless we receive a subsequent claim that includes the therapy codes.  In order to avoid denials, please wait to submit these claims until you are ready to bill for the therapy services.  For more information please refer to section 30 of the Medicare Claims Processing Manual [PDF].

Claims Filing

Send all SNF facility claims for HMSA's Akamai Advantage, PPO and HMO members to:

HMSA - UB-04 Claims (Facility)
P.O. Box 32700
Honolulu, HI 96803-2700

UB-04 Highlights: Sample Claim – Medicare Exhaust

See UB-04 Highlights: Sample Claim - Medicare Exhaust [PDF] for a sample of the claim explained below.

Explanation of sample claim

Notes:

• If rehabilitation RUG codes are billed for HMSA Akamai Advantage members and no rehabilitation therapy ancillary revenue codes are included on the claim, the claims will be denied unless we receive a subsequent claim that includes the therapy codes. In order to avoid denials, please wait to submit these claims until you are ready to bill for the therapy services. For more information please refer to section 30 of the Medicare Claims Processing Manual [PDF].
  • Form Locator 44: Refer to CPT modifier codes above.
  • Form Locator 50: Refer to the Exhaustion of Medicare Benefits section of Coordination of Benefits with Medicare for more information.

Revision History