August 13, 2010
Skilled Nursing Facility (SNF) Overpayments
When a beneficiary is in a Part A covered stay in a Skilled Nursing Facility (SNF), most DMEPOS items must be billed through the SNF, rather than to the DME MAC, due to consolidated billing requirements. If a DMEPOS item is billed to the DME MAC and there is a record of a SNF stay in the Common Working Files, the claim will be denied.
Sometimes the DME MAC may approve and pay a DMEPOS claim and later discover that the beneficiary was in a SNF on the date of service. This information is provided to the DME MAC through what is called an Informational Unsolicited Response (IUR) Report. When the DME MAC receives an IUR Report, any paid claims will be adjusted and an overpayment will be created.
Recently it was identified that some claims that were included on the IUR Report were not being included in the overpayment requests due to file size restraints. The Centers for Medicare and Medicaid Services (CMS) instructed us to clear out all IUR overflow files and generate overpayment requests. This has resulted in overpayment requests for claims with dates of service as old as 2007.
All remaining Jurisdiction C overpayment requests due to the IUR overflow issue will be sent out by August 20, 2010. The IUR file size capacity has been expanded to prevent the overflow issue from occurring in the future. Note that you may still receive SNF overpayment requests in the future, but when you do they will be more current.
To avoid SNF overpayments, you should routinely contact the Medicare beneficiary to ensure that they are not in a SNF. You may also utilize our Interactive Voice Response (IVR) unit to obtain SNF stay information on individual beneficiaries. For information about our IVR, please visit our Customer Service page.
For additional information about consolidated billing requirements for SNF residents, refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 6.
For addition information about overpayments, refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 12.