CMS Holding Some Skilled Nursing Facility Claims

November 7, 2019
Policy Snapshot
Patient Driven Payment Model (PDPM), Centers for Medicare and Medicaid (CMS), Payment, Practitioners

As the Centers for Medicare & Medicaid Services (CMS) has undertaken the implementation of the Patient Driven Payment Model (PDPM), it is holding a limited number of Skilled Nursing Facility (SNF) claims while making further refinements to its claims processing system.

Specifically, CMS is holding claims with:

  • Dates of service October 1, 2019, or later
  • Type of Bill (TOB) inpatient services (21X) and swing bed services (18X) subject to the SNF Patient Driven Payment Model (PDPM)
  • Multiple line items, Health Insurance Prospective Payment System (HIPPS) codes with different rate codes (revenue code 0022).

SNFs typically bill these claims on monthly cycles. Claims with single HIPPS codes were previously being held but are now being released for processing. CMS anticipates releasing the remaining held claims in late November, once it completes systems testing to ensure accurate and timely payment. As of November 1, fewer than 50 claims are being held.

In addition, CMS underpaid some SNF inpatient services (21X) and swing bed services (18X) claims for dates of service in October 2019 with a single line item, single HIPPS code. CMS is automatically reprocessing those claims; no provider action is needed.

CMS will continue to provide updates as further information develops.