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End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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May 5, 2021

SNF Benefit Period Waiver Claims

This article provides additional billing guidance for Skilled Nursing Facility (SNF) benefit period waiver claims during the COVID-19 Public Health Emergency (PHE). SNFs should continue to reference the criteria to determine when it is appropriate to document on a claim that the patient meets the requirement for the waiver and billing instructions found in the CMS MLN Matters® article SE2011External PDF.

Billing Instructions

To bill for the benefit period waiver:

  • Submit a final discharge claim on day 101 with patient status 01 (discharge to home).
  • Readmit the beneficiary to start the benefit period waiver.

For ALL admissions under the benefit period waiver (within the same spell of illness):

  • Complete a 5-day PPS Assessment. (The interrupted stay policy does not apply.)
  • Follow all SNF Patient Driven Payment Model (PDPM) assessment rules.
  • Include the HIPPS code derived from the new 5-day assessment on the claim.
  • The variable per diem schedule begins from Day 1.

For ALL SNF benefit period waiver claims, include the following (within the same spell of illness):

  • Condition Code DR – Identifies the claim as related to the PHE
  • Condition Code 57 (readmission) – Will bypass edits related to the 3-day stay being within 30 days
  • COVID100 in remarks – Identifies the claim as a benefit period waiver request

Additional Billing Guidance

  • Providers must abide by all other SNF billing guidelines (including Part B claims with dates of service that overlap a SNF waiver claim).
  • The additional 100 SNF benefit days may be utilized at any time within the same spell of illness; however, all 100 days cannot be billed on a single claim due to PDPM.
  • Continue to bill claims monthly in sequential order. Any claim billed with all 100 benefit days will be returned to the provider.
  • If a prior waiver claim has processed, please add a note in remarks on the subsequent claim, such as: COVID100 – 2nd waiver claim.
  • If the current claim plus the prior claims paid under the benefit period waiver exceed 100 days, the claim will be processed as a partial reject for benefits exhaust.
  • When the additional 100 days have been utilized:
    • Report the following on the final waiver claim:
      • Occurrence Code A3 and the date benefits exhausted
      • Benefits Exhaust in remarks
    • Continue to bill Medicare no-pay claims until the beneficiary is discharged and report Benefits Exhaust in remarks.

SNF Benefit Period Waiver Claim Example

The example below illustrates how to bill multiple claims during a SNF waiver spell of illness when the beneficiary is discharged with the resumption of SNF care within the same spell of illness.

The waiver period begins during the SNF stay/claim for dates of service 07.05.2020 – 07.31.2020. The beneficiary remains in SNF care until discharged to the hospital on 08.15.2020. The beneficiary then returns to the SNF on 08.18.2020 (new admission). The beneficiary remains in SNF care until discharged to home on 11.05.2020. All 100 additional benefit days for the SNF benefit period waiver are utilized.

 

Claim DOS

Admission Date

Patient Status

Condition Code(s)

Occurrence Code/Date

Value Code(s)

Remarks Page

Days Utilized on Claim

Total # of Days Utilized For Waiver

 

 

 

Claim #1

7/5/20 - 7/31/20

7/5/2020

30

DR 57

50 (7/8/2020)

80 - 27.00
82 - 7.00
09 - 1.00

COVID100

20 Full days
7 Co days

27 days

 

 

 

 

 

 

 

 

 

 

Claim #2

8/1/20 - 8/15/20

7/5/2020

02

DR 57

50 (7/8/2020)

80 - 14.00
82 - 14.00
09 - 1.00

COVID100

14 Co days

41 days

 

 

 

 

 

 

 

 

 

 

Claim #3

8/18/20 - 8/31/20

8/18/2020

30

DR 57

50 (8/22/20)

80 - 14.00
82 - 14.00
09 - 1.00

COVID100

14 Co days

55 days

 

 

 

 

 

 

 

 

 

 

Claim #4

9/1/20 - 9/30/20

8/18/2020

30

DR 57

50 (8/22/20)

80 - 30.00
82 - 30.00
09 - 1.00

COVID100

30 Co days

85 days

 

 

 

 

 

 

 

 

 

 

Claim #5

10/1/20 - 10/31/20

8/18/2020

30

DR 57

50 (8/22/20)
A3 (10/15/2020)

80 - 15.00
82 - 15.00
81 - 16.00
09 - 1.00

COVID100

15 Co days 16 Non-cov'd

100 days (100th day = 10/15/20)

 

 

 

 

 

 

 

 

 

 

Claim #6

11/1/20 - 11/30/20

8/18/2020

01

DR

50 (8/22/2020)

81 - 29.00

BENEFITS EXHAUST

29 Non-Cov'd

No add ‘l benefit days remain.

*** Claims 1-5 will each process outside of CWF (‘X’ tape flag) and each will have its own accrete (shadow) claim that does post to CWF.

*** Claim 6 will process as a full benefits exhaust rejection. It will also post to CWF and will have no shadow claim either.

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