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Provider Manual

Consolidated Billing for Medicare Advantage Members

Last Updated on October 01, 2019

Security Health Plan Medicare Advantage follows Consolidated Billing rules for members in a Medicare covered skilled nursing facility (SNF) stay.

The consolidated billing rule states that the SNF is responsible to bill for all rendered services, including those performed by outside providers, during a Medicare covered Part A stay except for those that are considered excluded from the consolidated billing requirement. See https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-B-MAC-Update.html for a list of services that are excluded from consolidated billing and can be billed directly by the provider to Security Health Plan.

Providers who perform services included in the consolidated billing requirement should seek reimbursement directly from the SNF. Any claims submitted directly to Security Health Plan will be denied CO190 ‘Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay’. It is the provider’s responsibility to validate with the SNF that the member is a resident in a covered Part A stay.

For example: when a Medicare Advantage member is in an approved Part A SNF stay and has a comprehensive metabolic panel performed outside the SNF at a clinic, the clinic should seek payment from the SNF rather than bill Security Health Plan for this test.

For members in a non-covered stay (Part B SNF stay) only specific therapy services are subject to consolidated billing. All other covered part B services can be separately billed to Security Health Plan.

Below are sites for more information on Consolidated Billing:
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html

https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2017-General-Explanation.pdf

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/SE0440.pdf