PDPM Claim Guidance Released

Carl J. Pucci in Finance & Reimbursement

CMS has released guidance on claims payments under the newly implemented PDPM model. Below is the AHCA bulletin with further details:

Earlier today, the Centers for Medicare and Medicaid Services (CMS) announced an update on claims payments under the newly implemented Patient-Driven Payment Model. As CMS has undertaken the implementation of the Patient Driven Payment Model (PDPM), they are holding a limited number of Skilled Nursing Facility (SNF) claims while they make further refinements to their 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 SNF Patient Driven Payment Model (PDPM); and
  • Multiple line items, Health Insurance Prospective Payment System (HIPPS) codes, with different rate codes (revenue code 0022). 

Typically, SNFs 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 they complete systems testing to ensure accurate and timely payment. As of November 1, less than 50 claims are being held.  

This is extremely positive news. In addition to what CMS has shared, there are some specific actions members must take in order for payments to go through.

  • Submit all claims, now, including multi-HIPPS code claims. Submitting all of your claims now is important for two reasons.
    1. CMS will begin the 14-day floor for claims processing from the date of submission. Therefore, when the fix goes into place the third week of November, your claims will be processed at that time - not 14 days later which would be the case if you wait until the third week in November. 
    2. If the November fix timeframe slips, having an accurate assessment of the number of outstanding multi-HIPPS code claims on hold will help to rapidly move forward with an alternative payment fix.
  • Communicate all MAC Experience. AHCA is still hearing about mixed Medicare Administrative Contractors (MACs) messaging. All MACs should be processing single HIPPS code claims and accepting multi-HIPPS code claims but holding them and indicating that multi-HIPPS code claims will be processed the third week of November. If your MAC is sharing different information, please alert AHCA at pdpm@ahca.org so we may alert CMS.
  • Use the Member Payment Experience Form. Please continue to complete AHCA's member payment experience form. AHCA will need this information to continue to assess the multi-HIPPS code claim impacts should the new targeted fix date slide.  
  • Sign up for AHCA's weekly webinar on Thursday, November 7 at 3pm ET. Register here for this week's webinar available to all AHCA members. This will focus on important PDPM updates and other implementation topics.

If you have questions, suggestions or concerns, please contact pdpm@ahca.org.


Carl J. Pucci
Chief Financial Officer
518-462-4800 x36