01-093 Overlapping Claims – Hospital Transfers During the PHE Notification of Medical Review

Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting post-payment coding review of claims for Medicare Part A billed on dates of service from March 1, 2020, through December 31, 2021. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.


A nationwide Public Health Emergency (PHE) was declared on January 31, 2020. In response, Secretary Alex Azar of the Department of Health and Human Services (HHS) authorized waivers and modifications on March 13, 2020, retroactive to March 1, 2020, under Section 1135 of the Social Security Act (SSA), which outlines the authority to waive requirements during national emergencies.

Waivers under Section 1135 of the SSA included several modifications related to hospital transfers during the PHE which allowed acute care facilities to accommodate the potential increased patient load due to COVID-19 and facilitate patient quarantine during the PHE. In June 2022, Noridian Healthcare Solutions, LLC (Noridian), as the current Supplemental Medical Review Contractor (SMRC), completed research and performed data analysis on inpatient facility claims transfers with overlapping dates of service (DOS) and identified a potential area of vulnerability.

Reason for Review

The SMRC is tasked to perform data analysis and conduct a coding review for inpatient facility transfers with overlapping DOS from March 1, 2020, through December 31, 2021.

The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

TOB Description
11x Hospital Inpatient
18x Hospital Swing Bed


Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

  1. Physician/Non-Physician Practitioner (NPP) Admission Orders
  2. Discharge summary from Hospital, Skilled Nursing, Continuous Care, and/or Respite Care facilities
  3. History and Physical reports (include medical history and current list of medications)
  4. Initial hospital inpatient care
  5. Subsequent hospital inpatient care
  6. Itemized breakdown of charges and subtotals per specific revenue code range(s) including the total charges of all revenue codes billed
  7. Admissions face sheet
  8. Discharge orders
  9. Transfer, Discharge, and/or revocation documentation
  10. Case Management/Social Worker discharge planning
  11. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  12. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
  13. Any other supporting/pertinent documentation
  14. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  15. PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met.


Social Security Act (SSA), Title XI

  • § 1135 Authority to Waive Requirements During National Emergencies.


  • § 1812 Scope of Benefits.
  • § 1815(a) Payment to Providers of Services.
  • § 1833(e) Payment of Benefits.
  • § 1861 Definitions of Services, Institutions, Etc.
  • § 1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer.
  • § 1877(g) Limitation on Certain Physician Referrals.
  • § 1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed.
  • § 1886(I)(i) Payment to Hospitals for Inpatient Hospital Services.
  • § 1893(b) and (f) Medicare Integrity Program.

42 Code of Federal Regulations (CFR)

  • § 411.15(k)(1) Particular Services Excluded from Coverage.
  • § 412 Subpart A – General Provisions.
  • § 413.1 Subpart A – Introduction and General Rules.

Federal Register

  • Final Rule Volume 85, No. 248. Regulatory Revisions in Response to the Public Health Emergency (PHE) for COVID–19; and Finalization of Certain Provisions from the March 31st, May 8th, and September 2nd Interim Final Rules in Response to the PHE for COVID–19. CMS-1734-F. Effective January 1, 2021. Retrieved from 2020-26815.pdf (govinfo.gov) external link icon.
  • Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC). Effective March 1, 2020. Retrieved from CMS-1744-IFC external link icon.
  • IFC Volume 85, No. 90. Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID–19 Public Health emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. May 8, 2020. Retrieved from 2020-09608.pdf (govinfo.gov) external link icon.

Internet-Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02

  • Chapter (Ch.) 1 Inpatient Hospital Services Covered Under Part A.
  • Ch. 16 General Exclusion from Coverage.

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

  • Ch. 1 General Billing Requirements.
  • Ch. 3 § Transfers.
  • Ch. 3 § 40.2.4 IPPS Transfers Between Hospitals.
  • Ch. 3 § 150 Long Term Care Hospitals.
  • Ch. 6 Inpatient Part A Billing and SNF Consolidated Billing.
  • Ch. 25 Completing and Processing the Form CMS-1450 Data Set.

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

  • Ch. 3 Verifying Potential Errors and Taking Corrective Actions.


Last Updated Jan 25, 2023