Reason Code 31608 Update

Consistent with regulations at 42 CFR 412.106 (b)(2)(i) and 412.106 (b)(2)(iii), patients who are enrolled in Medicare Advantage (administered through Medicare Part C) should also be included in the Medicare fraction. These days will be included in the Medicare/SSI fraction, but in order for them to be counted, the hospital must submit an informational only bill (TOB 11X) which includes Condition Code 04 to their Medicare contractor. This will ensure that these days are included in the hospital's SSI ratio for Fiscal Year 2007 and beyond.

Inpatient Rehabilitation Facilities and Long Term Care Hospitals are also required to submit informational only bills with Condition Code 04 for MA patients.

(Teaching hospitals do not need to submit additional claims with Condition Code 04 as they already submit claims for Indirect Medical Education for MA beneficiaries with Condition Code 04 and 69. We will capture SSI information from these claims.)

Claims hitting Reason Code 31608 are claims from providers that have been excluded from this regulation (i.e. Critical Access Hospitals and Inpatient Psychiatric Facilities).

As a result of much confusion on the processing of claims hitting this reason code, we were awaiting further clarification from the Centers for Medicare & Medicaid Services (CMS) before proceeding with further processing of these claims. We have received the clarification from CMS; therefore beginning October 26, 2009, claims hitting this reason code will now be returned to the provider, who should submit these claims to the MA plan if the provider hasn't already done so.

We apologize for any inconvenience this may have caused. If you have any questions regarding this, please contact your provider customer service area.

Page Last Updated: Thursday, 18-Mar-2010 05:49:20 CDT