I am receiving a denial from Anthem Managed Care for inpatient skilled nursing with a reason code of M86-Service denied because payment already made for same/similar procedure within set time frame. Can anyone help me with this?? We never received any payment for these dos and/or claim
I believe that this is hitting a "consolidated billing" edit.
The service date on the claim is within the date range of the patient’s stay at a SNF and therefore, services fall under consolidated billing
SNF Consolidated Billing:
payment for the majority of services provided to beneficiaries in a Medicare covered SNF stay are included in a bundled prospective payment made through the Part A to the SNF. Basically, Medicare already paid for the services.
CMS.gov has a specific list of the services that are included
The SNF could have submitted incorrect admit/discharge dates to Medicare
Although it’s not the most accurate denial code, it may also be caused by incorrect placement or incorrect plan type (managed care)
Resolution:
Find out what skilled nursing facility the patient was at during the date of service; the Medicare portal will show admit/discharge dates and the name; but you might find the facility name in the patient medical record
Contact the SNF to confirm admit/discharge dates
If the patient was there, then the SNF qualified services must be billed directly to the SNF for reimbursement; this can sometimes be complicated
The SNF should reimburse at Medicare rates
If the dates with Medicare don’t match what the SNF says, then they must call to update; and then have Medicare reprocess your claim