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Tips to prevent reject reason code U5233

You receive this reason code indicating the admission date falls within a risk Group Health Organization (GHO) paid period, or a Medicare Advantage plan. The beneficiary was or is enrolled in a Medicare replacement plan for the date(s) of service billed and the claim should be filed to that plan for payment.

A claim may overlap a GHO period because it was open at the time of billing, but subsequently closed by the time the provider researched the reason for rejection. The best way to avoid this reason code is to verify the beneficiary has original Medicare right before you submit the claim.

There are several ways to obtain beneficiary eligibility to determine if in a GHO:

  • Users can access eligibility information via direct data entry (DDE).
  • Contact the interactive voice response (IVR) system by calling 877-602-8816.
    • Note: Customer service representatives cannot assist you with eligibility information and are required by CMS to refer you to the IVR.
  • 270/271 Eligibility transactions - You can obtain eligibility information in a batch format for several beneficiaries.
  • Confirm the beneficiary's eligibility via SPOT.
  • Upon admission for Medicare covered services, review all insurance cards the beneficiary may hold and verify the information on the card with the patient or their legal representative to determine if all the information is valid.

In addition, CMS requires providers to submit "no pay claims" to the MAC to report the patient's Medicare Advantage inpatient days, and bill certain inpatient claims for reimbursement through the Part A cost report. The MACs reimburse for disproportionate share hospital (DSH), indirect medical education (IME), direct graduate medical education (DGME), and nursing allied health (N&AH). This type of duplicate billing is often referred to as "shadow billing" since claims are submitted to both the Medicare Advantage plan for payment and MAC as "no pay" or "information only" billing.

Refer to the Part A Reason Code Lookup for a description associated with the Medicare Part A reason code(s). Enter a valid reason code into the box and click the submit button.

IPPS hospitals with disproportionate share of low-income patients

If a hospital meets the DSH definition, an additional operating cost payment will be made.

Inpatient prospective payment system (IPPS) hospitals and inpatient rehabilitation facility (IRF) hospitals or units are required to submit informational only bills for purposes of capturing the Medicare Advantage patient's inpatient days for inclusion in the supplemental security income (SSI) ratio. This ratio is used in the DSH and low-income patient (LIP) for the IRF's PPS calculations. This also applies to long-term care hospitals (LTCHs), even though they do not directly receive DSH, as an estimate of what the facility would have received under DSH if they were an acute care facility becomes part of the LTCH outlier calculation.

Claim submission guidelines are as follows: 

  • Type of bill = 11X
  • Condition code 04
  • Covered days and charges
  • Revenue code 0024 containing CMG (case-mix groups) A9999 and include the discharge date in the service date field (only required by IRFs)

Approved teaching IPPS hospitals indirect medical education (IME) 

Approved teaching hospitals submit informational only bills for IME payment. The purpose is to capture the Medicare Advantage patient's inpatient days for inclusion in the SSI ratio and the Provider Statistics and Reimbursement Report (PS&R) type 118. 

Claim submission guidelines are as follows: 

  • Type of bill = 11X
  • Condition codes 04 and 69
  • Covered days and charges

Hospitals and units excluded from IPPS for DGME and N&AH education

Non-IPPS hospitals and units submit their Medicare Advantage claims to their respective MAC to be processed as no-pay bills, so the inpatient days can be reported on the patient's record and PS&R type 118 for DGME payment purposes through the cost report. This applies to rehabilitation, psychiatric, long-term care, children's and cancer hospitals, plus rehabilitation and psychiatric units. 

Claim submission guidelines are as follows: 

  • Type of bill = 11X
  • Condition codes 04 and 69
  • Non-covered days and charges

Skilled nursing facilities (SNFs) and swing bed units

SNF providers must submit bills for beneficiaries enrolled in Medicare Advantage plans and receiving skilled care to take benefit days from the beneficiary and update the beneficiary's spell of illness in the Medicare's Common Working File (CWF) system.

Claim submission guidelines are as follows: 

  • Type of bill = 21X or 18X
  • Condition code 04
  • Covered days and charges

 

References