Medicare advantage

[nnordhaus]

I have a few patients that were admitted to the hospital before the end of the year and their insurance changed as of 01/01/2026 but they remained in the hospital. According to CMS the active insurance on admission is responsible until discharge § 422.318 Special rules for coverage that begins or ends during an inpatient hospital stay. I have appealed UHC and their response is "Medicare product and for the professional claims we are not liable. Please tell your provider they need to submit to the carrier who is active for the claim DOS. For the inpatient stay itself, since that is paid DRG and cannot be split then we would pay for that whole claim, but professional does not work that way. Their guidance is from CMS." Does anyone have experience with this situation and where you successful at overturning the decision?

 

[sls314]

I have a few patients that were admitted to the hospital before the end of the year and their insurance changed as of 01/01/2026 but they remained in the hospital. According to CMS the active insurance on admission is responsible until discharge § 422.318 Special rules for coverage that begins or ends during an inpatient hospital stay. I have appealed UHC and their response is "Medicare product and for the professional claims we are not liable. Please tell your provider they need to submit to the carrier who is active for the claim DOS. For the inpatient stay itself, since that is paid DRG and cannot be split then we would pay for that whole claim, but professional does not work that way. Their guidance is from CMS." Does anyone have experience with this situation and where you successful at overturning the decision?

What UHC told you was correct.

When a patient enrolls or disenrolls in a Medicare Advantage plan and it overlaps an inpatient stay, the Inpatient PPS facility would bill the plan in effect as of the date of admission.

Any non-PPS provider, including professional claims, would be split by date of service and billed to the appropriate plan in effect at that DOS.

You can find the full citation in the Medicare Claims Processing Manual. Page 257 of the PDF at this link - I've also included a screenshot of it. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf