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CMS Update to SNF Billing Specific to Veterans Administration (Demo 31) Claims Under PDPM

Dan Ciolek

The Centers for Medicare and Medicaid Services (CMS) recently published MLN Matters Article MM11513 that impacts SNFs that furnish services ordinarily covered by Medicare but are furnished to veterans eligible for both Veterans Administration (VA) and Medicare benefits and also having Medicare supplemental insurance.  Specifically, as per transmittal CR 11513, MACs will terminate use of code AAA00 as of October 1, 2019 and will update the edit with a workaround that ensures that the default ZZZZZ Health Insurance Prospective Payment System (HIPPS) code is present on VA Demo 31 claims and is properly processed.  The workaround will expire on April 6, 2020.   

Background
Current law permits the VA to collect appropriate Medicare coinsurance and deductible amounts from supplemental insurers for claims for supplies and services ordinarily covered by Medicare but furnished:

• At VA facilities; and 
• For veterans eligible to receive both VA health and Medicare benefits and also having Medicare supplemental insurance. 

To facilitate this process, the Centers for Medicare & Medicaid Services (CMS) entered into an interagency agreement with the VA whereby CMS will help the VA work with the designated CMS MAC to adjudicate claims for these services to produce remittance advices equivalent to those ordinarily produced for Medicare claims. Medicare does not pay these claims, but the remittance advices show how much Medicare would have paid had the claims been payable by Medicare along with the applicable deductibles and coinsurance. In adjudicating a claim and generating these remittance advice notices, the CMS MAC must verify that the services provided are covered benefits, certify admission where appropriate, conduct prepayment utilization screening, and authorize payment. CMS has a single A/B MAC (A) and (B) to process these claims. The remittance advices, sent by the VA to the supplemental insurers, will help the insurers determine payment amounts they owe to the VA.  With the SNF PPS transition from RUG-IV to PDPM, provider VA Demo 31 claim default HIPPS coding must also change from AAA00 to ZZZZZ, effective October 1, 2019.  Details regarding the VA Claims Adjudication Services Project are located in Chapter 37 of the Medicare Claims Processing Manual.

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