Additional edits

The A/B MAC (A) must perform the following additional edits and investigate adjustment requests the provider submits:

• A full denial once the bill is paid, except to accomplish retraction of a duplicate payment; 

• A change in DRG based on a change in age or sex; 

• A change in deductible; 

• An adjustment request that changes a previously submitted QIO adjustment request; 

• An adjustment of a bill due to a change in utilization or spell data on another bill; 

• A reopening to change a no-payment bill to a payment bill;

• A reopening to pay a previously denied line item; 

• An adjustment request the provider initiates with a claim change reason code equal to D7, with the Medicare payment amount equal to or greater that the previously paid amount; or 

• An adjustment request with a claim change reason code equal to E0, and the claim is for a PPS provider. The A/B MAC (A) must investigate if the change is from patient status 02, transferred to another acute care facility.

Late Charges

Providers billing under Inpatient Hospital PPS, Outpatient PPS, SNF PPS, or HHA PPS may not bill late charges, nor will the contractor accept such bills, for any type of PPS service, inpatient or outpatient. Charges omitted from the original bill must be submitted on an adjustment bill that contains all pertinent charges including those billed earlier. When the provider submits late charges on bills to the A/B MAC (A) as bill type XX5, these bills contain only additional charges. Adjustment requests and not late charge bills should be submitted for

• Services on the same day as outpatient surgery subject to the ASC limit, 

• ESRD services paid under the composite rate, 

• All inpatient accommodation charges, and 

• All inpatient PPS ancillaries as adjustment requests 

The provider may submit the following charges omitted from the original paid bill to the A/B MAC (A) as late charges:

• Any outpatient services other than the exceptions stated in this paragraph. This includes late charges for HHA services under either Part A or Part B, hospice services, hospital outpatient services except those on the day of ambulatory surgery subject to the ASC payment limitation, RHC services, OPT services, SNF outpatient services, CORF services, FQHC services, CHMC services, and ESRD services not included in the composite rate; and

• Any inpatient SNF ancillaries or inpatient hospital ancillaries other than from PPS hospitals. The hospital may not submit late charges (XX5) for inpatient accommodations. The hospital must submit these as adjustments (bill type XX7).

The A/B MAC (A) has the capability to accept XX5 bill types electronically and process them as initial bills except as described in the following paragraph. 

The A/B MAC (A) also performs the following edit routines on any XX5 type bills received:

• Pass all initial bill edits, including duplicate checks. 

• Must not be for any of: Inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, or ESRD services included in the composite rate. These are rejected back to the hospital with the message, “This change requires an XX7 debit-only or XX8 cancel-only request from you. Late charges are not acceptable for inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, or ESRD services included in the composite rate.” 

• When an XX5 suspends as a duplicate, (dates of service equal or overlapping, provider ID equal, HICNs equal, and patient surname equal), the A/B MAC (A) must determine the status of the original paid bill. If it is denied, the A/B MAC (A) must deny the late charge bill. 

• If an xx5 does not suspend as a potential duplicate, the A/B MAC (A) rejects it back to the provider with the message, “No original bill paid. Please combine and submit a single original bill (XX1).” 

• If the original bill was approved and paid, the A/B MAC (A) compares the revenue codes on the original paid bill with the associated late charge bill:

° For all providers (any bill type), if any are the same, and are revenue codes 041x, 042x, 043x, 044x, 063x, 076x, or 091x, the A/B MAC (A) or (HHH) rejects the bill back to the provider with the message, “You must submit an adjustment (7) to the original paid bill. Revenue codes subject to utilization review are duplicated on the late charge bill.” 

° For HHAs (bill type 32X, 33X, or 34X), the A/B MAC (HHH) must apply the same logic for the following additional revenue codes. If any are the same and are revenue codes 0291, 0293, 055x, 056x, 057x, 058x, 059x, 060x, 066x, the A/B MAC (HHH) rejects the bill back to the provider with the message, "You must submit an adjustment (xx7) to the original paid bill. Revenue codes subject to utilization review are duplicated on the late charge bill."