Documents concerning payment of Part B despite a Part A Denial

A February 1, 2010 decision by the Medicare Appeals Council (Council) found in favor of the appellant (O’Connor Hospital in San Jose, CA). This decision is consistent with a March 14, 2005 decision by the Council, which found in favor of that appellant (University of Medicine and Dentistry of New Jersey).

Both cases involved Administrative Law Judge (ALJ) decisions to deny Part A claims by the hospitals, which were first paid but later determined to be not appropriate for inpatient admission and therefore not payable under Medicare Part A.

The Council, in both these cases, found that CMS in fact has current policies in place that direct contractors to pay a provider for Part B services rendered, even if they were never billed as such in the case of a Part A claim’s denial.

The following documents contain the decisions by Council:

• In the matter of O’Connor Hospital [PDF, 7 pgs, 77KB]

The following documents are referenced in the O’Connor Hospital decision:

• The Social Security Act
• Section 1862 (a)(1)(A) of the Social Security Act
• Medicare Benefits Policy Manual
• Section 1816 of the Social Security Act
• 42 CFR §421.100 Intermediary functions
• Medicare Claims Processing Manual
• 42 CFR §405.1046 Medicare Program: Changes to the Medicare Claims Appeal Procedures; Final Rule (12/09/2009)