# Billing Medicare

Contents

[3.1 About Medicare Billing 3-3](#about-medicare-billing)

[3.1.1 RPMS Third Party Billing and Medicare Claims Creation
3-4](#rpms-third-party-billing-and-medicare-claims-creation)

[3.2 Common Working File (CWF) 3-5](#common-working-file-cwf)

[3.3 Medicare Claim Change Condition Codes
3-5](#medicare-claim-change-condition-codes)

[3.4 Provider/Supplier Types 3-6](#providersupplier-types)

[3.4.1 Medicare Part A Providers 3-6](#medicare-part-a-providers)

[3.4.2 Medicare Part B Suppliers/Practitioners
3-7](#medicare-part-b-supplierspractitioners)

[3.5 Procedure for Billing Medicare
3-8](#procedure-for-billing-medicare)

[3.5.1 Outpatient Medicare Part A 3-8](#outpatient-medicare-part-a)

[3.5.2 Outpatient Medicare Part B 3-9](#outpatient-medicare-part-b)

[3.5.3 Inpatient Medicare Part A 3-9](#inpatient-medicare-part-a)

[3.5.4 In/Outpatient Medicare Part A 3-9](#inoutpatient-medicare-part-a)

[3.6 Inpatient Medicare Part B 3-9](#inpatient-medicare-part-b)

[3.6.1 Billing Medicare Part B 3-9](#billing-medicare-part-b)

[3.6.2 Inpatient Medicare Part B only
3-12](#inpatient-medicare-part-b-only)

[3.7 Ambulatory Surgery Center Billing -- Medicare
3-12](#ambulatory-surgery-center-billing-medicare)

[3.7.1 Editing a Claim for Facility Billing
3-12](#editing-a-claim-for-facility-billing)

[3.7.2 Billing for Professional Component
3-12](#billing-for-professional-component)

[3.7.3 Billing for Anesthesia Services
3-16](#billing-for-anesthesia-services)

[3.7.4 Medicare Ambulatory Surgery Billing Procedure
3-19](#medicare-ambulatory-surgery-billing-procedure)

[3.8 Medicare Secondary Payer (MSP) 3-20](#medicare-secondary-payer-msp)

[3.8.1 Working Aged 3-21](#working-aged)

[3.8.2 Disability 3-21](#disability)

[3.8.3 End Stage Renal Disease (ESRD)
3-22](#end-stage-renal-disease-esrd)

[3.8.4 Liability/Automobile Medical or No-Fault/Personal Injury\
Protection Insurance
3-22](#liabilityautomobile-medical-or-no-faultpersonal-injury-protection-insurance)

[3.8.5 Veterans 3-22](#veterans)

[3.8.6 Worker's Compensation 3-23](#workers-compensation)

[3.8.7 Black Lung 3-23](#black-lung)

[3.8.8 Provider Responsibilities under MSP
3-24](#provider-responsibilities-under-msp)

[3.8.9 Submitting Medicare Secondary Payer (MSP) Claims
3-24](#submitting-medicare-secondary-payer-msp-claims)

[3.9 Medicare Secondary Payer (MSP) Claims Investigation
3-25](#medicare-secondary-payer-msp-claims-investigation)

[3.10 Medicare Timely Filing 3-26](#medicare-timely-filing)

[3.10.1 Part A Timely Filing 3-26](#part-a-timely-filing)

[3.10.2 Part B Timely Filing 3-27](#part-b-timely-filing)

[3.11 Claims Resubmission Guidelines
3-29](#claims-resubmission-guidelines)

[3.11.1 Steps for Approving a Secondary/Tertiary Claim in RPMS
3-29](#steps-for-approving-a-secondarytertiary-claim-in-rpms)

[3.11.2 Steps for Exporting a Claim: 3-30](#steps-for-exporting-a-claim)

[3.11.3 Steps for Reprinting a Claim for Resubmission
3-30](#steps-for-reprinting-a-claim-for-resubmission)

[3.12 Reimbursement for Clinical Nurse Specialist or Nurse Practitioner
3-31](#reimbursement-for-clinical-nurse-specialist-or-nurse-practitioner)

[3.13 Reimbursement for Physician Assistant
3-31](#reimbursement-for-physician-assistant)

## About Medicare Billing

The Centers for Medicare/Medicaid (CMS) is the regulatory agency for
Medicare, Medicaid, and Managed Care Organizations. It is mandated that
each facility submit electronically, Medicare and Medicaid claims in the
HIPAA 837 format.

The IHS fiscal intermediary and carrier for Medicare is Trailblazer
Health Enterprises, LLC. Tribes, Federally Qualified Health Center
(FQHC), rural health centers, and other non-IHS entities may have other
fiscal intermediaries or carriers. Most clinics have arranged with the
intermediary/carrier to have claims transmitted electronically.

Reimbursement for covered inpatient ancillary services and outpatient
services is based on all-inclusive rates negotiated annually by IHS and
by the Center for Medicare/Medicaid (CMS). Services **included in the
IHS all-inclusive rates** are:

-   devices (other than dental) to replace all or part of an internal
    body organ, such as colostomy equipment and supplies

-   certain ambulance services

-   laboratory; radiology; emergency room and outpatient facility
    services

-   other diagnostic services

-   physical therapy

-   speech pathology

-   occupational therapy

-   dialysis in the facility or home

-   other medical services such as injection of vaccines

For Ambulatory Surgical Centers (ASC), reimbursement is based on rates
published in the Federal Register. A deductible and coinsurance applies
to the outpatient services.

For the Medicare flat all inclusive rate, it is recommended that the
correct E&M code be billed for Part A and Part B, even though some of
the Federally Qualified facilities will have their RPMS system default
to an agreed upon code by Medicare for billing purposes.

As with all insurers, the correct CPT codes should be coded at the
facility, but the billing process should be done according to payer
guidelines. All fees should be updated -- CPT, HCPCS, Dental, ASC.

Along with these updates your room rates need to be updated. Room rates
can be updated by using the CHS claims your facility receives from the
private facilities to which you send your patients. Complete a
comparison and document as indicated in the following example.

  ------------------------------------------------------------------------
  Revenue Code            Facility #1  Facility #2  Previous FY Proposed
  Description                                                   
  ----------------------- ------------ ------------ ----------- ----------
                                                                

                                                                

                                                                

                                                                
  ------------------------------------------------------------------------

RPMS transfer claims data from PCC into the Third Party Billing package.
Some facilities are using a Commercial Off-the-Shelf (COTS) product for
billing the insurer. If an IHS site is using other software, the data
must interface with the RPMS Third Party Billing and Accounts Receivable
applications.

### RPMS Third Party Billing and Medicare Claims Creation

An option located on the RPMS Third Party Billing Site parameters menu
allows a site to customize the claims creation process for Medicare.
This option can also be accessed from the Location Edit module.

The prompt is labeled **Medicare Part B**? The user can choose one of
the following:

-   **YES** -- Allows the system to generate Outpatient claims. These
    claims are generated with a Visit Type of 131 and are usually set up
    in the Insurer File as All-Inclusive. These are used mainly for FQHC
    sites that do not have the Part B authority, since the all-inclusive
    rate includes Part B.

-   **NO** -- Allows the system to generate two claims, an outpatient
    claim and a professional component claim:

```{=html}
<!-- -->
```
-   Visit Type 131 -- Outpatient

-   Visit Type 999 -- Professional Component

131 -- Outpatient Facilities that are hospital-based will generally set
their prompts up for this.

-   **ONLY** -- Allows the system to generate professional claims. These
    claims are generated with a visit type of 000 -- Professional
    Component. These claims are generated with the intention of billing
    a fee-for-service (itemized) claim for Medicare services. This type
    of claim is used primarily for Freestanding Health Centers.

## Common Working File (CWF)

The Common Working File (CWF) reorganizes certain claims processing
functions to simplify and improve overall Medicare claims processing, by
creating localized databases containing total beneficiary histories. CWF
was developed by the CMS Bureau of Program Operations and was designed
to

-   Create a beneficiary data set that contains all entitlement and
    utilization information in one location.

-   Increase program savings by detecting additional duplicate and
    inappropriate payments.

-   Enhance utilization review opportunities because all beneficiary
    history is in one file.

-   Avoid costly adjustment processing and overpayment recovery
    activities with pre-payment edits, and perform pre-payment A/B data
    exchange edits within the claims process.

## Medicare Claim Change Condition Codes

1.  These codes are specific to Medicare.

Claim Change Condition Codes

  -----------------------------------------------------------------------
  Valid Code    Code Description
  ------------- ---------------------------------------------------------
  D0            Change to Service Dates

  D1            Changes to Charges

  D2            Changes to Revenue Codes/HCPCS

  D3            Second or subsequent interim PPS bill

  D4            Change in Grouper input

  D5**\***      Cancel only to correct a HICN or provider identification
                number

  D6**\***      Cancel only to repay a duplicate payment or overpayment
                (includes cancellation of an outpatient bill containing
                services required to be included on the inpatient bill)

  D7            Change to make Medicare the Secondary Payer

  D8            Change to make Medicare the Primary Payer

  D9            Any other change

  E0            Change in Patient Status

  **\***D5 and  
  D6 are for    
  XX8 Type of   
  Bill only.    
  -----------------------------------------------------------------------

## Provider/Supplier Types

The following list of provider/supplier types is provided as an example
for an Indian Health Services facility.

-   Ambulance Service Supplier

-   Ambulatory Surgical Center

-   Audiologist

-   Certified Clinical Nurse Specialist

-   Certified Nurse Midwife

-   Certified Registered Nurse Anesthetist

-   Clinical/Group Practice

-   Clinical Psychologist

-   Community Mental health Center

-   Comprehensive Outpatient Rehabilitation Facility

-   Critical Access Hospital

-   Durable medical Equipment, Prosthetics, Orthotics, or Supplies

-   End Stage Renal Disease Facility

-   Federally Qualified Health Center - for guidelines, go to this
    website:

<http://www.cms.hhs.gov/center/fqhc.asp>

-   Histocompatibility Lab

-   Home Health Agency

-   Hospice

-   Hospital

-   Hospital Department Billing for Part B Practitioner Services

-   Independent Clinical Laboratory

-   Independent Diagnostic Testing Facility

-   Indian Health Services Facility (See below instructions)

For information related to these and other Medicare provider/supplier
types, go to this website:

<http://www.trailblazerhealth.com/>

Descriptions are available for the provider/supplier types, related to
the application process for Medicare.

### Medicare Part A Providers

Contact the local CMS [Regional
Office](http://www.cms.hhs.gov/providers/enrollment/contacts/), which
will provide guidance and any initial forms required to begin the
enrollment process.

### Medicare Part B Suppliers/Practitioners

  -------------- --------------------------------------------------------
  **Contact:**   TrailBlazer Health Enterprises, LLC\
                 Provider Services\
                 P. O. Box 650544\
                 Dallas, TX 75265-0544\
                 Phone: (866) 528-1602

  -------------- --------------------------------------------------------

TrailBlazer will provide guidance and any initial forms required to
begin the enrollment process.

-   Licensed Clinical Social Worker

-   Mammography Screening Center

-   Managed Care Organization

-   Mass Immunization Roster Biller

-   Medical Faculty Practice Plan

-   Multi-Specialty facility or Group Practice

-   Nurse Practitioner

-   Occupational Therapist in Private Practice

-   Occupational Therapy (Group)

-   Organ procurement Organization

-   Other Medical Care Group

-   Outpatient Physical Therapy-Occupational Therapy/Speech Pathology
    Services

-   Pharmacies

-   Physical therapist in Private practice

-   Physical Therapy (group)

-   Physiotherapy

-   Physician Assistant

-   Physician

-   Portable X-ray Facility

-   Psychiatric Unit (of hospital)

-   Public Health/Welfare Agency

-   Registered Dietitian/Nutrition Professional

-   Rehabilitation Agency

-   Rehabilitation Unit (of hospital)

-   Religious Non-medial

-   Rural Health clinic

-   Rural Primary Care Hospital

-   Skilled Nursing Facility

-   Voluntary Health/Charitable Agency

## Procedure for Billing Medicare

TrailBlazers offers the online GPNet software for Medicare billing and
follow-up. Other Fiscal Intermediaries (FI) may offer other types of
software programs. However, it is strongly recommended that each
facility that bills to TrailBlazers, use the GPNet software to do
Medicare billing and follow-up.

A GPNet user manual is available at this website:

<http://www.trailblazerhealth.com/parta/downloads/2003GPNet.pdf>

There are multiple bill types. The three-digit alphanumeric code gives
three specific pieces of information.

-   The first digit identifies the type of facility.

-   The second classifies the type of care.

-   The third indicates the sequence of the bill in this particular
    episode of care. This is also known as the "frequency" code.

### Outpatient Medicare Part A 

+------------+----------------+----------------------------------------+
| Bill Types |                |                                        |
+------------+----------------+----------------------------------------+
| First      | Type of        | 1 -- Hospital                          |
| digit      | Facility       |                                        |
|            |                | 8 -- Hospital ASC Surgery              |
+------------+----------------+----------------------------------------+
| Second     | Bill           | 1 -- Inpatient Part A                  |
| Digit      | Classification |                                        |
|            |                | 2 -- Inpatient Part B Only             |
|            |                |                                        |
|            |                | 3 -- Outpatient                        |
+------------+----------------+----------------------------------------+
| Third      | Frequency      | 0 -- Nonpayment/Zero Claim             |
| Digit      |                |                                        |
|            |                | 1 -- Admit through Discharge Claim     |
|            |                |                                        |
|            |                | 2 -- Interim -- First Claim            |
|            |                |                                        |
|            |                | 3 -- Interim -- Continuing Claim       |
|            |                |                                        |
|            |                | 4 -- Interim -- Last5 -- Late Charge   |
|            |                | Only Claim                             |
|            |                |                                        |
|            |                | 6 -- Adjustment of Prior Claim         |
|            |                |                                        |
|            |                | 7 -- Replacement of Prior Claim        |
|            |                |                                        |
|            |                | 8 -- Void /Cancel of a Prior Claim     |
+------------+----------------+----------------------------------------+

### Outpatient Medicare Part B

+----------+--------------------------------------------+--------------+
| Bill     |                                            |              |
| Types    |                                            |              |
+==========+============================================+==============+
| Ou       | 13X, 14X -- Hospital                       | Part B Only  |
| tpatient |                                            |              |
|          | 23X -- Skilled Nursing Facility            |              |
|          |                                            |              |
|          | 34X -- Home Health (not PPS)               |              |
|          |                                            |              |
|          | 71X -- Rural Health Clinic (RHC)           |              |
|          |                                            |              |
|          | 72X -- Renal Dialysis Facility (RDF)       |              |
|          |                                            |              |
|          | 73X -- Federally Qualified Health Center   |              |
|          | (FQHC)                                     |              |
|          |                                            |              |
|          | 74X -- Outpatient Rehabilitation Facility  |              |
|          | (ORF)                                      |              |
|          |                                            |              |
|          | 75X -- Comprehensive Outpatient            |              |
|          | Rehabilitation Facility (CORF)             |              |
|          |                                            |              |
|          | 76X -- Community Mental Health Center      |              |
|          | (CMHC)                                     |              |
|          |                                            |              |
|          | 83X -- Hospital Out surgery                |              |
|          |                                            |              |
|          | 85X -- Critical Access Hospital (CAH)      |              |
+----------+--------------------------------------------+--------------+
| Ou       | 32X, 33X -- Home Health (PPS)              | Part A and B |
| tpatient |                                            |              |
+----------+--------------------------------------------+--------------+

### Inpatient Medicare Part A

+----------+--------------------------------------------+--------------+
| Bill     |                                            |              |
| Types    |                                            |              |
+==========+============================================+==============+
| I        | 11X -- Hospital                            | Part A Only  |
| npatient |                                            |              |
| Part A   | 18X -- Swing Bed                           |              |
|          |                                            |              |
|          | 21X -- Skilled Nursing Facility            |              |
|          |                                            |              |
|          | 41X -- Religious non-medical Healthcare    |              |
|          | situation                                  |              |
+----------+--------------------------------------------+--------------+

### In/Outpatient Medicare Part A

  --------------------------------------------------------------------------
  Bill Types                                                  
  --------------- ------------------------------------------- --------------
  In/outpatient   81X, 82X - Hospice                          Part A Only
  Part A                                                      

  --------------------------------------------------------------------------

## Inpatient Medicare Part B

### Billing Medicare Part B

**A. Assignment**

Under the participating physician program, the physician agrees to
accept payment from Medicare (80% of the allowable) plus from the
patient, the remaining 20% of reasonable charges after the \$100
deductible has been met.

The payment goes directly to the physician. Effective September 1, 1992,
patients are not allowed to submit claims to Medicare (with five
exceptions).

Physicians, practitioners, and suppliers who fail to submit claims are
subject to civil money penalties of up to \$2,500 for each claim.
Situations when a patient may file a claim are:

-   Services covered by Medicare for which the patient has other
    insurance that should pay first;

-   Services not covered by Medicare for which the patient wants a
    formal Part B coverage determination;

-   Services provided by a physician who refuses to submit the claim;

-   Services provided outside the United States; and

-   When durable medical equipment is purchased from a private source.

**Reasonable charges** is the amount that Medicare lists on the
Remittance Advice (RA) -- formerly known as Explanation of Benefits
(EOB) -- which is the allowed (approved) charge for the procedure. This
charge may be lower than the fee the physician lists on the claim.

When a physician accepts assignment, he or she may bill the
non-beneficiary only 20% of what Medicare considers a reasonable
(allowed) charge.

Interest fees cannot be assessed to Medicare patients. Do not collect
the Medicare co-payment up front. However, it is permissible to collect
the deductible up front for non-beneficiaries only.

**B. Nonparticipating (non-par) Physician**

A physician who does not participate has an option regarding assignment.
The physician may not accept assignment for all services or may have the
option of accepting assignment for some services and collecting from the
patient for other services performed at the same time and place.

An exception to this policy is mandatory assignment for clinical
laboratory tests and services by physician assistants.

Usually, a nonparticipating physician who is not accepting assignment
collects the total fee from the patient but may bill no more than the
Medicare limiting charge. **Limiting charges** is a percentage limit on
fees, specified by legislation, that non-par physicians may bill
Medicare beneficiaries above the fee schedule amount.

Medicare sends the payment check to the patient.

**C. Patient's Signature Authorization**

Signatures are required on all HCFA-1500 claims forms, except
Medicare/Medicaid cases.

Sometimes it is not possible to obtain the signature of a Medicare
patient because of confinement in a nursing facility or hospital or at
home. In such cases, physicians can obtain a lifetime signature
authorization from the patient. The lifetime beneficiary claim
authorization and information release form is an example that can be
used for assigned and non-assigned Medicare claims and kept in the
patient's medical records.

The HCFA-1500 form should be submitted with the notation in the
patient's signature block: "Patient's payment authorization on file." If
the claim will be automatically crossed over and paid by a Medigap
carrier, obtain a lifetime signature authorization for the Medigap
carrier.

**D. Time Limits**

The time limit for sending in claims is the end of the year following
the year in which services were used.

**E. Required Form**

The form that physicians use to submit their claims to Medicare is
HCFA1500.

**F.** RA documents are received by the physician and the patient, with
the Medicare check going to the Physician.

**G.** The following list shows the kinds of physicians' services that
Medicare Part B will help pay for.

-   Medical and surgical services by a doctor of medicine (MD), doctor
    of osteopathy (DO or MD), or a doctor of dental medicine or dental
    surgery (DDS).

-   Certain services by podiatrists (DPM)

-   Limited services by chiropractors (DC), such as subluxation of the
    spine.

### Inpatient Medicare Part B only

+----------+--------------------------------------------+--------------+
| Bill     |                                            |              |
| Types    |                                            |              |
+----------+--------------------------------------------+--------------+
| I        | 12X -- Hospital                            | Part B Only  |
| npatient |                                            |              |
| Part B   | 22X -- Skilled Nursing Facility            |              |
+----------+--------------------------------------------+--------------+

## Ambulatory Surgery Center Billing -- Medicare

For the most up-to-date guidance for Ambulatory Surgery Center (ASC)
services, got to this website:

<http://www.trailblazerhealth.com/>

### Editing a Claim for Facility Billing

For instructions for editing a claim for facility billing, see the *RPMS
Third Party Billing User's Manual*, which is available at this website:

<http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=documentschoice>

### Billing for Professional Component

The following screen output displays a sample walkthrough of billing for
professional component.

2.  The information provided in this example is for demonstration
    purposes only.

+-----------------------------------------------------------------------+
| Select Add/Edit Claim Menu Option:                                    |
|                                                                       |
| Type ED and press Enter.                                              |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
| EDITING A CLAIM (BILLING CATARACT EXTRACTION)                         |
|                                                                       |
| Select CLAIM or PATIENT:                                              |
|                                                                       |
| Enter the claim number (see the following claim example)              |
|                                                                       |
| \* is where the Billing Technician needs to review                    |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| Claim Number: 12346                                                   |
|                                                                       |
| \...\...\...\...\...\...\...\...\...\.... (CLAIM SUMMARY)             |
| \...\...\...\...\...\...\...\...\...\...                              |
|                                                                       |
|                                                                       |
|                                                                       |
| \_\_\_\_\_\_\_ Pg-1 (Claim Identifiers)                               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Pg-4 (Providers)                 |
| \_\_\_\_\_\_\_\_\_\_\_                                                |
|                                                                       |
| Location..: GALLUP MED C \| Attn: COX,JAMES                           |
|                                                                       |
| Clinic\....: DAY SURGERY \| Oper: COX,JAMES                           |
|                                                                       |
| Visit Type: PROFESSIONAL COMPONENT\|\_\_\_\_\_\_\_\_\_\_ Pg-5A        |
| (Diagnosis) \_\_\_\_\_\_\_\_\_\_                                      |
|                                                                       |
| Bill From: 11-29-2005 Thru: 11-29-2005 \| 1) CATARACT LEFT EYE        |
|                                                                       |
| \|                                                                    |
|                                                                       |
| \_\_\_\_\_\_\_\_ Pg-2 (Billing Entity)                                |
| \_\_\_\_\_\_\_\_\_\|\_\_\_\_\_\_\_\_ Pg-8 (CPT Procedures)            |
| \_\_\_\_\_\_\_\_                                                      |
|                                                                       |
| MEDICARE ACTIVE \| 1) CATARACT SURG W/IOL, 1 STAGE                    |
|                                                                       |
| Press Enter to go to the next page.                                   |
|                                                                       |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~ PAGE 1     |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~            |
|                                                                       |
| Patient: 99999 Claim Number: 12346                                    |
|                                                                       |
| \...\...\...\...\...\...\...\...\..... (CLAIM IDENTIFIERS)            |
| \...\...\...\...\...\...\...\...\.....                                |
|                                                                       |
|                                                                       |
|                                                                       |
| \[1\] Clinic\...\...\...\....: DAY SURGERY                            |
|                                                                       |
| \* \[2\] Visit Type\...\...\...: PROFESSIONAL COMPONENT               |
|                                                                       |
| \* \[3\] Bill Type\...\...\....: 999                                  |
|                                                                       |
| \[4\] Billing From Date..: 10/19/2004                                 |
|                                                                       |
| \[5\] Billing Thru Date..: 10/19/2004                                 |
|                                                                       |
| \[6\] Super Bill #\...\....:                                          |
|                                                                       |
| \[7\] Mode of Export\.....: 837 PROF (HCFA)                           |
|                                                                       |
| \[8\] Visit Location\.....: GALLUP MED C                              |
|                                                                       |
| \-\-\-\-\-\-\-\-\-\                                                   |
| -\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\- |
| \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- |
|                                                                       |
| Desired ACTION (Edit/View/Next/Jump/Back/Quit): N//                   |
|                                                                       |
| Press Enter to go to the next page.                                   |
|                                                                       |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~ PAGE 2         |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~          |
|                                                                       |
| Patient: 99999 Claim Number: 12346                                    |
|                                                                       |
| \...\...\...\...\...\...\...\...\...\...\.... (INSURERS)              |
| \...\...\...\...\...\...\...\...\...\....                             |
|                                                                       |
|                                                                       |
|                                                                       |
| To: MEDICARE PART A - TEXAS \* Bill Type\...: 999                     |
|                                                                       |
| 12800 INDIAN SCHOOL RD, NE Proc. Code..: CPT4                         |
|                                                                       |
| ALBUQUERQUE, NM MEDIA-CARE Export Mode.: 837 PROF (HCFA)              |
|                                                                       |
| (888)763-9836 Flat Rate\...: N/A                                      |
|                                                                       |
| \...\...\...\...\...\...\...\...\...                                  |
| \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.... |
|                                                                       |
|                                                                       |
|                                                                       |
| BILLING ENTITY STATUS POLICY HOLDER                                   |
|                                                                       |
| ===============================================================       |
|                                                                       |
| \[1\] MEDICARE ACTIVE Patient, Demo                                   |
|                                                                       |
| \-\-\-\-\-\-\-\-\-\                                                   |
| -\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\- |
| \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- |
|                                                                       |
| WARNING:072 - EMPLOYMENT STATUS CODE UNSPECIFIED                      |
|                                                                       |
| WARNING:075 - EMPLOYER LOCATION UNSPECIFIED                           |
|                                                                       |
| \-\-\-\-\-\-\-\-\-\                                                   |
| -\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\- |
| \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- |
|                                                                       |
| Desired ACTION (Edit/View/Next/Jump/Back/Quit): N//                   |
|                                                                       |
| Press Enter to go to the next page.                                   |
+-----------------------------------------------------------------------+
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~ PAGE 3   |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~              |
|                                                                       |
| Patient: 99999 Claim Number: 12346                                    |
|                                                                       |
| \...\...\...\...\...\...\...\...\...\...\... (QUESTIONS)              |
| \...\...\...\...\...\...\...\...\...\.....                            |
|                                                                       |
| \* \[1\] Release of Information..: YES From: 04/04/2005 Thru:         |
|                                                                       |
| \* \[2\] Assignment of Benefits..: YES From: 04/04/2005 Thru:         |
|                                                                       |
|  \[3\] Accident Related\...\.....: NO                                 |
|                                                                       |
|  \[4\] Employment Related\...\...: NO                                 |
|                                                                       |
|  \[5\] Emergency Room Required.:                                      |
|                                                                       |
|  \[6\] Special Program\...\...\...: NO                                |
|                                                                       |
|  \[7\] Outside Lab Charges\.....:                                     |
|                                                                       |
|  \[8\] Date of First Symptom\...:                                     |
|                                                                       |
|  \[9\] Date of Similar Symptom.:                                      |
|                                                                       |
| \[10\] Date of 1st Consultation:                                      |
|                                                                       |
| \[11\] Referring Phys. (FL17) :                                       |
|                                                                       |
| \[12\] Case No. (External ID)..:                                      |
|                                                                       |
| \[13\] Medicaid Resubmission No:                                      |
|                                                                       |
| \[14\] PRO Approval Number\.....:                                     |
|                                                                       |
| \[15\] HCFA-1500B Block 19\.....:                                     |
|                                                                       |
| \[16\] Supervising Prov.(FL19): Date Last Seen:                       |
|                                                                       |
| Enter RETURN to continue or \'\^\' to exit:                           |
|                                                                       |
| Press Enter to go to the next page.                                   |
|                                                                       |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~ PAGE 4     |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~            |
|                                                                       |
| Patient: 99999 Claim Number: 12346                                    |
|                                                                       |
| \...\...\...\...\...\...\...\...\...\.... (PROVIDER DATA)             |
| \...\...\...\...\...\...\...\...\...\...                              |
|                                                                       |
|                                                                       |
|                                                                       |
| PROVIDER NUMBER DISCIPLINE                                            |
|                                                                       |
| ==============================================================        |
|                                                                       |
| (attending)PROVIDER, DR 8HZ343 OPHTHALMOLOGIST                        |
|                                                                       |
| (rendering)PROVIDER, DR 8HZ343 OPHTHALMOLOGIST                        |
|                                                                       |
|                                                                       |
|                                                                       |
|  Desired ACTION (Add/Del/View/Next/Jump/Back/Quit): N//               |
|                                                                       |
|                                                                       |
|                                                                       |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~ PAGE 5A        |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~          |
|                                                                       |
| Patient: 99999 Claim Number: 12346                                    |
|                                                                       |
| \...\...\...\...\...\...\...\...\...\...\... (DIAGNOSIS)              |
| \...\...\...\...\...\...\...\...\...\.....                            |
|                                                                       |
|                                                                       |
|                                                                       |
| BIL ICD9                                                              |
|                                                                       |
| SEQ CODE - Dx DESCRIPTION PROVIDER\'S NARRATIVE                       |
|                                                                       |
| ===============================================================       |
|                                                                       |
|  1 366.9 - UNSPECIFIED CATARACT CATARACT NOS                          |
|                                                                       |
| Desired ACTION (Edit/View/Next/Jump/Back/Quit): N//                   |
|                                                                       |
| Press Enter to go to the next page.                                   |
|                                                                       |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~ PAGE 8B        |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~            |
|                                                                       |
| Patient: 99999 Claim Number: 12346                                    |
|                                                                       |
| Mode of Export: 837 PROF (HCFA)                                       |
|                                                                       |
| \...\...\...\...\...\...\...\...\.... (SURGICAL PROCEDURES)           |
| \...\...\...\...\...\...\...\...\....                                 |
|                                                                       |
|                                                                       |
|                                                                       |
| BIL SERV REVN CORR CPT                                                |
|                                                                       |
| SEQ DATE CODE DIAG CODE PROVIDER\'S NARRATIVE UNITS CHARGE            |
|                                                                       |
| ===============================================================       |
|                                                                       |
|  1 CHARGE DATE: 10/19/2004                                            |
|                                                                       |
| \*\*\* 1 66984 CATARACT SURG W/IOL, 1 STAGE 1 951.00                  |
|                                                                       |
|   =========                                                           |
|                                                                       |
| \$951.00                                                              |
|                                                                       |
|                                                                       |
|                                                                       |
| Desired ACTION (Add/Del/Edit/Seq/View/Next/Jump/Back/Quit/Mode): N//  |
+-----------------------------------------------------------------------+
| Keep pressing ENTER until you get to the LAST PAGE (8J)               |
|                                                                       |
| Press ENTER, and the system prompts you back to PAGE 1.               |
|                                                                       |
| KEY ENTER (A) FOR APPROVAL                                            |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
| \*\*\*\*\* 837 PROF (HCFA) CHARGE SUMMARY \*\*\*\*\*                  |
|                                                                       |
| Corr                                                                  |
|                                                                       |
|  Charge Date POS TOS Description Diag Charge Qty                      |
|                                                                       |
| \-\-\-\-\-\-\-\-\-\                                                   |
| -\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\- |
| \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- |
|                                                                       |
| 10-19-2004 22 2 66984 1 951.00 1                                      |
|                                                                       |
| \-\-\-\-\-\-\-\-\--                                                   |
|                                                                       |
| TOTAL CHARGE 951.00                                                   |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
| Form Locator Override edits exist for POS/TOS                         |
|                                                                       |
|                                                                       |
|                                                                       |
| ENTER                                                                 |
|                                                                       |
|                                                                       |
|                                                                       |
| SUMMARY                                                               |
|                                                                       |
| ===============================================================       |
|                                                                       |
|                                                                       |
|                                                                       |
| Previous Bill                                                         |
|                                                                       |
| Form Charges Payments Write-offs Non-cvd Amount                       |
|                                                                       |
| \-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\--           |
| \-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\--           |
|                                                                       |
| 837 PROF (HCFA) 951.00 0.00 0.00 0.00 951.00                          |
|                                                                       |
| ========== ========== ========== ========== ==========                |
|                                                                       |
| 951.00 0.00 0.00 0.00 951.00                                          |
|                                                                       |
|                                                                       |
|                                                                       |
| Do You Wish to APPROVE this Claim for Billing?                        |
|                                                                       |
| Enter (Y) YES                                                         |
+-----------------------------------------------------------------------+

### Billing for Anesthesia Services

The following screen output displays a sample walkthrough of billing for
anesthesia services.

3.  The information provided in this example is for demonstration
    purposes only.

+-----------------------------------------------------------------------+
| Patient: 99999 Claim Number                                           |
|                                                                       |
| \...\...\...\...\...\...\...\...\...\.... (CLAIM SUMMARY)             |
| \...\...\...\...\...\...\...\...\...\...                              |
|                                                                       |
|                                                                       |
|                                                                       |
| \_\_\_\_\_\_\_ Pg-1 (Claim Identifiers)                               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Pg-4 (Providers)                 |
| \_\_\_\_\_\_\_\_\_\_\_                                                |
|                                                                       |
| Location..: GALLUP MED C \| Attn: COX,JAMES E                         |
|                                                                       |
| Clinic\....: DAY SURGERY \|                                           |
|                                                                       |
| Visit Type: PROFESSIONAL COMPONENT \|\_\_\_\_\_\_\_\_\_\_ Pg-5A       |
| (Diagnosis) \_\_\_\_\_\_\_\_\_\_                                      |
|                                                                       |
| Bill From: 10-19-2004 Thru: 10-19-2004 \| 1) CATARACT NOS             |
|                                                                       |
| \|                                                                    |
|                                                                       |
| \_\_\_\_\_\_\_\_ Pg-2 (Billing Entity)                                |
| \_\_\_\_\_\_\_\_\_\|\_\_\_\_\_\_\_\_ Pg-8 (CPT Procedures)            |
| \_\_\_\_\_\_\_\_                                                      |
|                                                                       |
| MEDICARE ACTIVE \| 1) CATARACT SURG W/IOL, 1 STAGE                    |
|                                                                       |
| \|                                                                    |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_ Pg-3 (Questions) \_\_\_\_\_\_\_\_\_\_\_\|      |
|                                                                       |
| Release Info: YES Assign Benef: YES \|                                |
|                                                                       |
| \|                                                                    |
|                                                                       |
| \|                                                                    |
|                                                                       |
| \_\_\_                                                                |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\|\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
|                                                                       |
|                                                                       |
| Desired ACTION (View/Appr/Next/Jump/Quit): N//                        |
|                                                                       |
| Press Enter to go to next page                                        |
|                                                                       |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~ PAGE 1       |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~            |
|                                                                       |
| Patient: 99999 Claim Number:                                          |
|                                                                       |
| \...\...\...\...\...\...\...\...\..... (CLAIM IDENTIFIERS)            |
| \...\...\...\...\...\...\...\...\.....                                |
|                                                                       |
|                                                                       |
|                                                                       |
| \[1\] Clinic\...\...\...\....: DAY SURGERY                            |
|                                                                       |
| \* \[2\] Visit Type\...\... ..: PROFESSIONAL COMPONENT                |
|                                                                       |
|  \* \[3\] Bill Type\...\..... : 999                                   |
|                                                                       |
| \[4\] Billing From Date..: 10/19/2004                                 |
|                                                                       |
| \[5\] Billing Thru Date..: 10/19/2004                                 |
|                                                                       |
| \[6\] Super Bill #\...\....:                                          |
|                                                                       |
| \* \[7\] Mode of Export\... .: 837 PROF (HCFA)                        |
|                                                                       |
|  \[8\] Visit Location\.....: GALLUP MED C                             |
|                                                                       |
| \-\-\-\-\-\-\-\-\                                                     |
| -\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\- |
| \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- |
|                                                                       |
| Desired ACTION (Edit/View/Next/Jump/Back/Quit): N//                   |
|                                                                       |
| Press Enter to go to next page                                        |
+-----------------------------------------------------------------------+
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~ PAGE 5A      |
|                                                                       |
| Patient: 99999 Claim Number:                                          |
|                                                                       |
| \...\...\...\...\...\...\...\...\...\...\... (DIAGNOSIS)              |
| \...\...\...\...\...\...\...\...\...\.....                            |
|                                                                       |
| BIL ICD9                                                              |
|                                                                       |
| SEQ CODE - Dx DESCRIPTION PROVIDER\'S NARRATIVE                       |
|                                                                       |
| ===============================================================       |
|                                                                       |
|  1 366.9 - UNSPECIFIED CATARACT CATARACT NOS                          |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
| Desired ACTION (Add/Del/Edit/Seq/View/Next/Jump/Back/Quit): N//       |
|                                                                       |
| Press Enter to go to next page.                                       |
|                                                                       |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~ PAGE 8G      |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~              |
|                                                                       |
| Patient: 99999 Claim Number:                                          |
|                                                                       |
| Mode of Export: 837 PROF (HCFA)                                       |
|                                                                       |
| \...\...\...\...\...\...\...\...\.... (ANESTHESIA SERVICES)           |
| \...\...\...\...\...\...\...\...\...                                  |
|                                                                       |
|                                                                       |
|                                                                       |
| REVN BASE  TIME TOTAL                                                 |
|                                                                       |
| CODE CPT - ANESTHESIA SERVICES CHARGE CHARGE CHARGE                   |
|                                                                       |
| ===============================================================       |
|                                                                       |
|                                                                       |
|                                                                       |
| Desired ACTION (Add/Del/Edit/View/Next/Jump/Back/Quit/Mode): N// (A)  |
|                                                                       |
| Type A (ADD)                                                          |
|                                                                       |
| ============ ADD MODE - ANESTHESIA SERVICES ===============           |
|                                                                       |
| Select Anesthesia (CPT Code): 00142 ANESTH, LENS SURGERY              |
|                                                                       |
| ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY                        |
|                                                                       |
| \...OK? Yes// (Yes)                                                   |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
| Anesthesia PROVIDER: MELO,FRANCISCO// FJM ANESTHESIOLOGIST            |
|                                                                       |
|                                                                       |
|                                                                       |
| Anesthesia BASE CHARGE: 183.7//                                       |
|                                                                       |
| Anesthesia PLACE OF SERVICE: 22// OUTPATIENT HOSPITAL                 |
|                                                                       |
| \* Anesthesia UNITS: 1**// 60**                                       |
|                                                                       |
|  \* Anesthesia MODIFIER: **AA**                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
| Attempting FILEMAN lookup\...                                         |
|                                                                       |
| \...OK? Yes// (Yes)                                                   |
|                                                                       |
| Press Enter for Yes.                                                  |
|                                                                       |
| \* Anesthesia START DATE/TIME: 101904@0900 (OCT 19, 2004@09:00)       |
|                                                                       |
| \* Anesthesia STOP DATE/TIME: 101904@1000 (OCT 19, 2004@10:00)        |
|                                                                       |
| Anesthesia OBSTETRICAL?:                                              |
|                                                                       |
|  \* Anesthesia TIME CHARGE: 167// **60**                              |
+-----------------------------------------------------------------------+
| Enter how the anesthesia should look after all required entry.        |
|                                                                       |
|                                                                       |
|                                                                       |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~ PAGE 8G              |
| \~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~\~    |
|                                                                       |
| Patient: 99999 Claim Number:                                          |
|                                                                       |
| Mode of Export: 837 PROF (HCFA)                                       |
|                                                                       |
| \...\...\...\...\...\...\...\...\.... (ANESTHESIA SERVICES)           |
| \...\...\...\...\...\...\...\...\...                                  |
|                                                                       |
|                                                                       |
|                                                                       |
| REVN BASE TIME TOTAL                                                  |
|                                                                       |
| CODE CPT - ANESTHESIA SERVICES CHARGE CHARGE CHARGE                   |
|                                                                       |
| ======                                                                |
| ===================================================================== |
|                                                                       |
| \[1\] 00142-AA ANESTHESIA FOR PROCEDURES ON EYE; 183.70 60.00 243.70  |
|                                                                       |
| LENS SURGERY                                                          |
|                                                                       |
| Start Date/Time: 19-OCT-2004 9:00 AM                                  |
|                                                                       |
| Stop Date/Time: 19-OCT-2004 10:00 AM                                  |
|                                                                       |
| ==========                                                            |
|                                                                       |
| \$243.70                                                              |
|                                                                       |
| Keep pressing ENTER until the system prompts you to return to the     |
| Main Menu.                                                            |
|                                                                       |
| Type A to approve the claim.                                          |
|                                                                       |
| \*\*\*\*\* 837 PROF (HCFA) CHARGE SUMMARY \*\*\*\*\*                  |
|                                                                       |
|  Corr                                                                 |
|                                                                       |
|  Charge Date POS TOS Description Diag Charge Qty                      |
|                                                                       |
| \-\-\-\-\-\-\-\-\                                                     |
| -\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\- |
| \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- |
|                                                                       |
| \* 10-19-2004 22 7 00142-AA 1 243.70 60                               |
|                                                                       |
| \-\-\-\-\-\-\-\-\--                                                   |
|                                                                       |
| TOTAL CHARGE 243.70                                                   |
|                                                                       |
| Form Locator Override edits exist for POS/TOS                         |
|                                                                       |
| Press Enter to go to next page.                                       |
|                                                                       |
| Previous Bill                                                         |
|                                                                       |
| Form Charges Payments Write-offs Non-cvd Amount                       |
|                                                                       |
| \-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\--           |
| \-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\--           |
|                                                                       |
| 837 PROF (HCFA) 243.70 0.00 0.00 0.00 243.70                          |
|                                                                       |
| ========== ========== ========== ========== ==========                |
|                                                                       |
| 243.70 0.00 0.00 0.00 243.70                                          |
|                                                                       |
|                                                                       |
|                                                                       |
| Do You Wish to APPROVE this Claim for Billing? (Y) YES                |
|                                                                       |
| Type YES to approve the claim.                                        |
+-----------------------------------------------------------------------+

### Medicare Ambulatory Surgery Billing Procedure

The regulatory agency for Medicare program is the Centers for Medicare
and Medicaid (CMS). Under the prospective payment system (PPS),
Attachment C -- for covered ambulatory surgery services, the
reimbursable rate is based on the Ambulatory Surgery center (ASC) Group
Rates published in the Federal Register. Medicare Part B deductibles and
coinsurances apply to eligible covered services.

The coder completes the coding for all ambulatory surgery visits. The
coding will be entered in the PCC menu.

The claims generator will convert and create a bill in the Third Party
Billing appliation overnight.

The biller will print out a Flag-As Billable Brief Summary listing and
will use this listing as a guide to what visits/claims to bill. The bill
type for Ambulatory surgery is 831.

All edits need to be accomplished to complete a "clean" claim. Once all
the edits have been made, the biller will determine the approval of the
bill and will submit the bill on the appropriate claim form, which will
be transmitted electronically.

-   Review the Inpatient or Ambulatory Surgery abstracts from UR.

-   Verify completeness and accuracy.

-   Enter the claims data into the system for processing.

-   Review data for completeness and accuracy.

**Type of Bills** (Locator 4 on the UB92)

-   **Inpatient Claims** **111**

The total days in the hospital has been determined to be medically
necessary based on the severity of the illness according to the
utilization review criteria, or stated another way, the services to the
patient have been labeled as "covered services."

-   **Ambulatory Surgery** **831**

This bill type is used to bill for ambulatory surgeries done on an
outpatient basis. Ambulatory surgery rates must be used.

-   **No Pay Claims** **110**

During the utilization review, the severity of the illness did not
warrant hospitalization. The utilization review will indicate "0 Bill".
Remarks should include why the services were not covered.

-   **Outpatient Claims** **131**

-   **Inpatient Part B Only** **121**

The severity of the illness has been determined not medically necessary
based on the utilization review criteria. Room and board for the
hospitalization are not covered nor are any provider visits.

-   **Other alternate resources** **117**

A claim was processed and paid; however, the patient had other alternate
resources that should have been billed. Using "117" will instruct the
system to "recoup" reimbursement.

## Medicare Secondary Payer (MSP)

Medicare Secondary Payer (MSP) is used by Medicare when Medicare is not
responsible for paying first. It is important to check if Medicare or
Medicaid has already been billed and take the appropriate action.

For accounts with two insurance companies, the RPMS Accounts Receivable
application requires documentation of the primary billing company.

By Federal law, Medicare is secondary payer to a variety of government
and private insurance benefit plans. Medicare should be viewed as the
secondary payer when a beneficiary can reasonably be expected to receive
medical benefits through one of more of the following means:

-   An Employer Group Health plan for **working aged** beneficiaries

-   A Large Group Health Plan for **disabled** beneficiaries

-   Beneficiaries eligible for **End State Renal Disease**

-   **Liability/Automobile medical or no-fault insurance/Personal Injury
    Protection (PIP)**

-   **Veterans Administration** (VA)

-   **Workers' Compensation** Plan

-   Federal **Black Lung** Program

Any conditional primary payment(s) made by Medicare for services related
to an injury is subject to recovery. Conditional payments can be made
on:

-   Liability

-   Automobile medical or no-fault insurance

-   Workers' Compensation

For more information on Medicare Secondary Payer, go to this website:

<http://www.cms.hhs.gov/MedicareSecondPayerandYou/>

### Working Aged

Medicare is secondary for the **Working Aged** when the following
conditions apply:

-   Employer Group Health Plan of 20 or more employees,

-   Employer Group Plan covers the same services as Medicare,

-   Beneficiary is age 65 or older,

-   Beneficiary is entitled to Part A (hospital insurance of Medicare,
    *and*

-   Beneficiary or spouse of beneficiary is actively employed and
    covered by an employer group plan by reason of his/her employment

### Disability

Medicare is secondary for beneficiaries who are under age 65 and are
entitled to Medicare due to a **disability** other than End State Renal
Disease (ESRD) for the following criteria:

-   The beneficiary has coverage under a Large Group Health Plan with
    100 or more employees,

-   The beneficiary is entitled to Medicare based solely on a disability
    (other than ESRD), *and*

-   The beneficiary is actively employed or covered as a dependent of an
    actively employed person covered under a Large Group Health Plan
    with 100 or more employees.

### End Stage Renal Disease (ESRD)

The **End Stage Renal Disease (ESRD)** criteria applies to individuals,
including dependent children who are entitled to Medicare on the basis
of ESRD and who are covered under an Employer Group Plan, regardless of
the size of the plan. The criteria are

-   If an Employer Group Health Plan (EGHP) is offered through an
    employer because of his/her employment or employment of spouse or
    other family member's active employment; then Medicare is secondary
    to an EGHP for individuals who have Medicare benefits based on ESRD.
    The beneficiary can be any age; *and*

-   The period in which Medicare is secondary is called the coordination
    of benefit period. Secondary benefits are payable for a period up to
    30 months.

### Liability/Automobile Medical or No-Fault/Personal Injury Protection Insurance

Section 953 of the Omnibus Budget Reconciliation Act of 1980, amended by
the Deficit Reduction Act of 1994, precludes Medicare payment for items
or services to the extent that payment has been made or can reasonable
be expected to be made under auto medical, Personal Injury Protection
(PIP), no-fault, or any **liability** insurance plan or policy,
including self-insurance plans.

Services that should be billed to these insurance plans are:

-   Services payable under one of the above plans (except third-party
    liability) -- that plan should be billed until all benefits are
    exhausted.

-   Any payments made by Medicare for services payable under one of
    these policies constitute overpayments and are subject to recovery.

-   Liability insurance plan is an exception to the above rule. The
    physician/supplier has the option to bill Medicare for conditional
    primary payment.

### Veterans

**Veterans** who are also entitled to Medicare may choose which program
will be responsible for payment for services that are covered by both
programs. Claims for services for which the veteran elects Medicare
coverage should be submitted to Medicare in the usual manner. A denial
from the VA is not needed prior to submitting a claim for Medicare.

Medicare will be primary to the VA in the following situations:

-   VA denies the services and the services are covered under Medicare.

-   Correspondence is received indicating "No VA Coverage."

Insurers frequently see the following situations with Medicare and VA:

-   If the VA is unable to provide treatment for the services at one of
    its own facilities or by one of its own physicians, they may refer
    the beneficiary to an outside facility or physician.

-   Pre-authorization is obtained from the VA to use an outside
    facility.

-   The beneficiary has been issued a "fee basis" card. This card is an
    agreement by the VA to pay up to a specified dollar amount for
    treatment of a specific disability or for any condition specified on
    the face of the "fee basis" card.

### Worker's Compensation

Federal law precludes payment for services payable under a **Worker's
Compensation** policy. If services are work-related, the Worker's
Compensation policy should be billed until all benefits are exhausted.

Medicare remains primary payer for services not related to Worker's
Compensation.

With Worker's Compensation:

-   Medicare may make payments for Medicare covered services, if not
    payable under the Worker's Compensation policy.

-   Services payable under a Worker's Compensation policy that have been
    paid by Medicare constitute overpayments and are subject to
    recovery.

-   A beneficiary's statement that an injury or illness is not
    work-related may be accepted in absence of reasonable doubt.

### Black Lung

Medicare will pay secondary to an insurance company paying for **Black
Lung** diagnosis with the exception of the United Mine Worker's
Association (UMWA). UMWA is their own government entity; therefore,
Medicare Part B will deny charges.

However, services rendered to these beneficiaries for conditions not
related to black lung diagnoses should be billed directly to Medicare,
such as cardiac failure brought on by renal failure. Medicare will pay
primary for services not related to black lung disease.

### Provider Responsibilities under MSP

Part A provider (hospitals):

-   Obtain billing information prior to providing hospital services,
    using the recommended Centers for Medicare and Medicaid Services'
    (CMS) questionnaire (or a questionnaire that asks similar types of
    questions).

-   Submit any MSP information to the intermediary, using condition and
    occurrence codes on the claim

Part B provider (physicians and suppliers):

-   Follow the proper claim rules to obtain MSP information, such as
    group health coverage through employment or non-group health
    coverage resulting from an injury or illness;

-   Inquire at the time of the visit if the beneficiary is taking legal
    action in conjunction with the services performed.

-   Submit an Explanation of Benefits (EOB) form to the designated
    carrier with all appropriate MSP information. If submitting an
    electronic claim, provide the necessary fields, loops, and segments
    to process an MSP claim.

For more information, go to the CMS website:

<http://www.cms.hhs.gov/MedicareSecondPayerandYou/>

### Submitting Medicare Secondary Payer (MSP) Claims

To ensure correct reimbursement when Medicare is secondary payer to
another insurance company, use the following instructions:

-   Screen Medicare beneficiaries for secondary coverage,

-   Send claims to the primary insurance and then to Medicare,

*and*

-   If you are filing a Medicare secondary claim on an HCFA-1500 claim
    form, list all services on the detail lines. Include a copy of the
    primary insurance company's Explanation of Benefits

-   If you file electronically, you do not need to include a copy of the
    primary insurance company's Explanation of Benefits. The claim does
    require the submission of three additional data elements:

```{=html}
<!-- -->
```
-   Medicare secondary type codes;

-   Amount paid by primary payer; and

-   Amount allowed by primary payer

The physician or provider must file a Medicare secondary claim, if
he/she receives the primary Explanation of Benefits directly from the
beneficiary.

**Item 11 of the HCFA-1500 must be completed.** By completing this item,
the physician or provider acknowledges having made a good faith effort
to determine whether Medicare is the primary or secondary payer.

-   If there is insurance primary to Medicare, enter the insured's
    policy or group number and proceed to Items 11a-11c.

-   If there is no insurance primary to Medicare, enter the word "NONE"
    and proceed to Item 12.

-   If there has been a change in the insured's insurance status, such
    as retired, enter the word "NONE" and proceed to 11b.

Item 11a is the insured's birth date and sex; 11b is the employer's
name, if applicable; and 11c is the nine-digit payer ID identification
number of the primary insurance plan or program.

## Medicare Secondary Payer (MSP) Claims Investigation 

Effective January 8, 2001, the **Coordination of Benefit (COB)**
contractor assumed responsibility for virtually all initial MSP
development activities formerly performed by Medicare intermediaries and
carriers. This means the COB contractor is charged with ensuring the
accuracy and timely update of data populated on Medicare's eligibility
database regarding other health insurance that is primary to Medicare.
The COB contractor also handles MSP-related inquiries, including those
seeking general MSP information, but not those related to specific
claims or recoveries.

The COB contractor is primarily an information gathering entity. A
variety of methods and programs are used to identify situations in which
Medicare beneficiaries have other health insurance this is primary to
Medicare:

  -----------------------------------------------------------------------
  Process                    Description
  -------------------------- --------------------------------------------
  Secondary Claim            When a claim is submitted with an
  Development                explanation of benefits (EOB) attached from
                             an insurer other than Medicare, a
                             questionnaire is sent to the beneficiary to
                             collect information on the existence of
                             other insurance that may be primary to
                             Medicare.

  Self-Report Development    A self-report covers the full spectrum of
                             MSP situations. Any source that contacts the
                             COB contractor initiates this type of
                             development process in order to address
                             these inquiries and to assure that the
                             information provided is accurate.

  Trauma Development         When a diagnosis appears on a claim that
                             information is received through
                             correspondence or on a claim that indicates
                             a traumatic accident, injury, or illness,
                             which might form the basis of MSP, a
                             questionnaire is sent to collect information
                             on the existence of other insurance that may
                             be primary to Medicare. This questionnaire
                             may be sent to the beneficiary, provider,
                             attorney, or insurer.

  CFR 411.25                 This process confirms MSP information
                             received from a third party payer
  -----------------------------------------------------------------------

## Medicare Timely Filing

### Part A Timely Filing

Under Medicare law, claims are accepted by the carrier for dates of
service in the current year, the previous year, and the last three
months (October, November, and December) of the year prior.

For purposes of the time limit, a hospital shall be deemed to have filed
a claim for payment for inpatient hospital services on the date it
submitted an admission notice for such services, provided the claim is
submitted within 60 days after the intermediary or Social Security
Administration, as appropriate, replied to the admission notice.

Where the hospital is establishing timely filing of the claim on this
basis (i.e., the claim would not otherwise be timely filed), it should
so note on the billing or an attachment to the billing, and indicate the
date the admission notice was sent and the date the reply was received.

Where there is a Social Security Administration (SSA) error (e.g.,
misrepresenting, delay, mistake, or other action of SSA or its
intermediaries or carriers) that causes the failure of the hospital to
file a claim for payment within the time limit, the time limit will be
extended through the last day of the sixth calendar month following the
month in which the error is rectified by notification to the hospital or
beneficiary, but not beyond December 31 of the third calendar year after
the year in which the services were furnished. (For services furnished
during October -December of a year, the time limit may be extended no
later than the end of the fourth year after that year.)

### Part B Timely Filing

For Medicare payment to be made for a claim for physician and other Part
B services reimbursable on a reasonable charge basis, the claim must be
filed no later than the end of the calendar year following the year in
which the service was furnished, except for services furnished in the
last 3 months of a year, where the time limit is December 31 of the
second year following the year in which the services were rendered. This
time limit was effective with claims filed after March 1968. (See §§
266.7 and 266.8 for effect of Federal non‑workdays and rules applicable
to claims received in the mail.)

For example: A patient received laboratory tests at a clinic in August
2004. The claim for reimbursement for such services must be billed on or
before December 31, 2005. If the tests were performed in October 2004,
the claim must be filed on or before December 31, 2006.

Where there is an administrative error (that is, misrepresentation,
delay, mistake, or other action of SSA or its intermediaries or
carriers) that causes the failure of the beneficiary or the hospital,
physician, or supplier to file a claim for payment within the time limit
specified in § 271, the time limit will be extended through the close of
the sixth calendar month following the month in which the error is
rectified.

Consideration of possible extension of the time limit on Part B
reasonable charge claims will be initiated only if there is a basis for
belief that the claimant (the enrollee or his representative or
assignee) has been prevented from timely filing by an administrative
error. For example, he states that official misinformation caused the
late filing, or the social security office calls to the intermediary\'s
attention a situation in which such error has caused late filing.

In some cases, a hospital may have incorrectly billed for a Part B
professional component as a hospital expense. For example, a
physician\'s services were erroneously considered entirely
administrative in nature and the error was not discovered until the
final cost settlement.

Where the claim which included the physician services was filed within
the time limit, it establishes protective filing for a subsequent
perfection of a Part B claim. Such claims will be considered filed as of
the date the incorrect billing was submitted to the intermediary
provided the usual claims information (e.g., the SSA-1554 in the case of
a hospital-filed claim) is submitted within 6 months after the month in
which the notice was sent that payment for the patient care services was
disallowed.

The perfected claim may be filed by the physician on the basis of
assignment, or by the hospital (where the hospital has a contractual
arrangement to bill and receive payment for the physician\'s services),
or may be filed by the patient on the basis of an itemized bill.

A hospital claim filed within the Part B time limit will not establish a
filing date for the related professional component where such component
was recognized and not included in the provider bill (e.g., no claim was
filed for the professional component as a non-provider expense because
the physician and hospital could not agree on the exact amount of the
component charge or who would bill for it).

Where the hospital bills for physician and hospital services under the
combined billing procedure presume that the billing is timely filed as
to the physician component if it is timely filed as to the hospital
component, and that it is not timely as to the physician component if it
is not timely filed as to the hospital component.

Where the time limit has expired on services reimbursable on a
reasonable charge basis, there is no requirement that a bill be filed.
However, where a person (or organization) accepts assignment within the
time limit, but fails to submit a timely claim, he is barred by the
terms of the assignment from collecting from the patient or other person
amounts in excess of the deductible and coinsurance involved.

For claims submitted electronically to Medicare via GPNet, the following
abbreviations may be returned for denied claims:

  ---------------- ------------------------------------------------------
  R status         Rejected

  T status         Return to Provider (RTP)

  D status         Medically denied

  Type of Bill     XXP (PRO adjustment) *or* XXI (Intermediary
                   adjustment)
  ---------------- ------------------------------------------------------

The original bill can be resubmitted on both the status of T or R, if
additional or corrected information is supplied. The original type of
bill frequency codes should be used. The T status cannot be adjusted
(XX7) or voided (XX8), since it is not considered an active bill.

## Claims Resubmission Guidelines

-   In some instances, the claim may not be considered unless billing
    errors are corrected. These Remittance Advices or Explanation of
    Benefits are routed back to the individual billing clerks for
    correction and then resubmitted to the respective insurer.

-   Claim resubmission may be done via fax, mail, or electronically.

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```
-   The filing limit for Medicaid varies by state, from as low as 120
    days to one year. Resubmission of claims is usually within 6 months
    from the date of the remittance advice.

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```
-   Medicare claims are accepted by the carrier for dates of service in:

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```
-   The current year

-   The previous year

-   October, November, December of the year prior to that

-   Resubmission for denied claims must be appealed within 4 months from
    the remittance date

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```
-   Most Private Insurance companies have a one year filing limit. Some
    private insurers are longer than one year. Resubmissions on denied
    claims must be completed by December 31 of the next calendar year

-   The claim may then be rolled for further billing to
    secondary/tertiary insurer as applicable.

### Steps for Approving a Secondary/Tertiary Claim in RPMS 

1, Exit the Accounts Receivable (A/R) menu.

2\. Go to the RPMS Third Party Billing application and select the
Add/Edit Claim Menu.

3\. At the prompt, type **EDCL (**Edit Claim Data) and press Enter..

a\. Examine claim for accuracy and make corrections if necessary.

b\. On **Page 1**, check for visit type and mode of export.

-   Visit type is set to Secondary or similar, based on site set up

-   Mode of export allows you to bill the claim on a HCFA 1500 or UB-92
    manually. Since Medicare/Medicaid claims are transmitted
    electronically by utilizing the HIPAA 837P and/or 837I, the mode of
    export needs to be changed to HCFA-1500 and/or UB-92 so claims can
    be resubmitted manually.

4\. On **Page 2**, select the billing entity and insurer address.

5\. On Page 3, review Assignment of Benefits and Release of Information.

6\. On **Page 4**, check for provider name and credential.

4.  If corrections are needed on Pages 5A through 9F, claim is routed to
    Billing technician.

7\. JO (Jump Zero) to claim summary.

8\. Type **A** to approve the claims.

9\. Verify the mode of export and correct dollar amount(s). Then type
**Y** (Yes) to approve claim.

10\. Exit EDCL.

### Steps for Exporting a Claim:

1\. Go to the Print Bills Menu, and select **EXPR** to export the
approved claim.

2\. Select form to be exported (HCFA-1500 or UB-92) and press Enter.

3\. Select a print device for the HCFA-1500 or UB-92 form by entering
the device for your printer, and press Enter.

### Steps for Reprinting a Claim for Resubmission

1\. Exit the Accounts Receivable (A/R) Menu.

2\. Got to REPR or reprint bill.

3\. At the prompt, type **1** for Selective Bill(s) and press Enter.

4\. Enter the claim number(s) and press Enter.

5\. Enter the print device and enter the device for your printer for
either the HCFA-1500 or UB-92 to reprint ADA.

6\. Press Enter to start the print jobs.

For all resubmissions, attach a copy of the Remittance Advice,
Explanation of Medicare Benefits, and Commercial insurance EOBs when
appropriate

## Reimbursement for Clinical Nurse Specialist or Nurse Practitioner

For the Clinical Nurse Specialist (CNS) or Nurse Practitioner (NP),
payments are only under assignment. Direct payments can be made to
either the NP or the facility, but only if no facility or other provider
charges are paid in connection with the service. Reimbursement would be
equal to 80 percent of the lesser of the actual charge or 85 percent of
the physician fee.

## Reimbursement for Physician Assistant

For the Physician Assistant (PA), payments are made under an assigned
basis. Since the PA services are performed under the direction of the
provider, all payments would be made to the provider or facility, but
only if no facility or other provider charges are paid in connection
with the service. Reimbursement for eligible services would be equal to
80 percent of the lesser of the actual charge or 85 percent of the
physician fee schedule.