Skilled nursing facility consolidated billing requirements for Medicare Advantage plans

Your skilled nursing facility (SNF) is required to use consolidated billing when submitting claims for post-acute inpatient SNF admissions for UnitedHealthcare Medicare Advantage members. 

With this requirement, you must bill for the entire package of care that residents receive during:

• A covered Part A SNF stay, or
• Physical, occupational and speech therapy services received during a non-covered SNF stay

What is consolidated billing?

Consolidated billing is an all-encompassing billing methodology similar to hospital bundled billing. Learn more at the CMS Consolidated Billing resource page.

When is consolidated billing required?

Consolidated billing is required for Medicare Advantage members who are receiving services in a:

• Part A covered SNF stay, which includes medical services as well as room and board
• Part B non-covered SNF stay, in which the Part A benefits are exhausted, but certain medical services are still covered. In this instance, room and board is not covered

Services that can be billed separately

There are a limited number of services that are excluded from the consolidated billing requirement.

For Medicare Advantage members in a covered Part A stay, these services can be billed separately:

• Physician's professional services
• Certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services
• Certain ambulance services, including:
  • Ambulance services that transport the beneficiary to the SNF initially
  • Ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF)
  • Roundtrip ambulance services rendered during the stay that transport the beneficiary off-site temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services
• Erythropoietin for certain dialysis patients
• Certain chemotherapy drugs
• Certain chemotherapy administration services
• Radioisotope service
• Customized prosthetic devices

Questions?

Please contact your Provider Advocate.