The CMS must record a day or charge as either covered or noncovered because of the
following:
Beneficiary utilization is recorded based upon days during which the patient received
hospital or SNF accommodations, including days paid by Medicare and days for which the
provider was held liable for reasons other than medical necessity or custodial care. Days
denied as not medically necessary or as custodial care are not charged against a
beneficiary's utilization record when the provider is determined to be liable.
The provider may claim credit on its cost report only for covered accommodations, days
and charges for which actual payment is made, i.e., provider liable days and charges are
not included. Data from the bill payment process are used in preparing the cost report.
The number of days and charges provided to the Pricer program affects the day and cost
outlier determinations and the DRG payment amount. Non-PPS provider days are
excluded from Pricer consideration.
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