Medicare Claims Processing Manual 
Chapter 2 - Admission and Registration Requirements 
 
Table of Contents 
(Rev. 4247, 03-01-19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
Transmittals for Chapter 2 
01 - Purpose of Chapter 
05 - Definition of Provider and Supplier 
10 - General Admission and Registration Rules 
10.1 - Medicare beneficiary identifiers 
10.1.1 - Changes to Medicare beneficiary identifiers 
10.1.2 - Contractor Procedures for Obtaining Missing or Incorrect 
Medicare beneficiary identifiers 
10.1.3 - Importance of Medicare beneficiary identifiers  
10.2 - Prohibition Against Waiver of Health Insurance Benefits as a Condition of 
Admission 
10.3 - Requiring Prepayment as a Condition of Admission is Prohibited 
10.4 - When Prepayment May Be Requested 
10.5 - Hospital and Skilled Nursing Facility (SNF) Verification of Prior Hospital 
Stay Information for Determining Deductible and Benefit Period Status 
10.6 - Hospitals May Require Prepayment for Noncovered Services 
10.7 - Compliance With Agreement 
10.8 - Request for Payment Should Be Obtained in All Cases as Protective 
Application for Hospital Insurance Benefits 
10.9 - A/B MAC (A) or (HHH) Requests to Verify Patients Medicare beneficiary 
identifier 
10.10 - A/B MAC (A) or (HHH) Learns Beneficiary is an HMO Enrollee 
10.11 - Retroactive Entitlement  10.12 - SNF Verification of Prior Hospital Stay and Transfer Requirements 
20 - Obtaining Information to Determine Whether to Bill Medicare or Another Payer 
20.1 - Provider Development of Medicare Secondary Payer 
30 - Provider/Supplier Obtaining/Verifying the Medicare beneficiary identifier and 
Entitlement Status  
30.1 - Cross-Reference of  Medicare beneficiary identifier 
30.2 - Health Insurance (HI) Card 
30.3 - Temporary Eligibility Notice 
30.4 - Certificate of Social Insurance Award 
30.5 - Medicare Summary Notice (MSN) 
30.6 - Provider Access to CMS and A/B MAC (A) or (HHH) Eligibility Data 
30.6.1 - Reserved 
30.6.1.1 - Part A Inquiry (HIQA) Screen Display 
30.6.1.2 - Part A Inquiry Reply (HIQAR) Screen Display 
30.6.1.3 - Part A Inquiry (HUQA) Data 
30.6.1.4 - Part A Inquiry Reply (HUQAR) Data 
30.6.1.5 - Health Insurance Query for Home Health Agencies 
(HIQH) 
30.6.2 - Reserved 
30.6.3 - Reserved 
30.6.4 - Reserved 
30.6.5 - Reserved 
30.6.6 - Reserved 
30.8 - Reserved 
30.10 - Reserved 
30.11 - Reserved 
30.12 - Reserved 
30.13 - Reserved 
30.14 - Reserved 
30.15 - Reserved 
30.16 - Reserved 
30.17 - Reserved 
30.18 - Reserved  30.19 - Reserved 
30.19.1 - Reserved 
30.19.2 - Reserved 
30.19.3 - Reserved 
30.19.4 - Reserved 
30.20 - Reserved 
30.21 - Requesting Assistance in Resolving Problem Areas in the Inquiry/Inquiry 
Response Procedures 
30.21.1 - HMO-Related Master File Corrections 
30.22 - Provider Problems Obtaining Entitlement Information 
50 - Critical Case Procedures - Establishing Entitlement Under Part A and B 
60 - Reserved 
60.1 - Reserved 
60.2 - Reserved 
70 - SSO Assistance in Resolving Entitlement Status Problems 
90 - Outpatient Hospital Registration Procedures 
90.1 - Patient Identification 
90.2 - Determining Whom to Bill 
90.3 - Source of Admission - Outpatient Hospital 
90.4 - Type of Bill 
90.5 - Definition of Diagnostic Services 
90.6 - Definition of Encounter 
100 - Reserved 
100.1 - Reserved 
110 - Reserved 
110.1 - Reserved 
120 - Reserved  01 - Purpose of Chapter 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
This chapter describes general requirements with respect to verifying an individuals 
Medicare eligibility and entitlement status for providers, suppliers, A/B MACs (A), (B), 
and (HHH), and DME MACs.  It also includes general requirements for hospitals for 
determining the source admission for use later in the claims process. 
 
05 - Definition of Provider and Supplier 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
This chapter uses the definition of provider and supplier found in 42 CFR 400.202.  
These are: 
 
Provider means a hospital, a CAH, a skilled nursing facility, a comprehensive 
outpatient rehabilitation facility, a home health agency, or a hospice that has in 
effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, 
or a public health agency that has in effect a similar agreement but only to furnish 
outpatient physical therapy or speech-language pathology services, or a 
community mental health center that has in effect a similar agreement but only to 
furnish partial hospitalization services. 
 
Supplier means a physician or other practitioner, or an entity other than a 
provider that furnishes health care services under Medicare. 
 
Note that while rural health clinics, Federally qualified health centers, and renal dialysis 
facilities are suppliers under the regulation, they submit most claims to A/B MACs (A). 
 
10 - General Admission and Registration Rules 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
The following is a general description of requirements and prohibited activities that apply 
to admission for inpatient services or registration for other healthcare services. 
 
Upon admission, Prospective Payment System (PPS) hospitals and acute care hospitals in 
areas with waivers from PPS are required to give the notice, An Important Message 
from Medicare, to beneficiaries (available at www.cms.gov/Medicare/Medicare-
General-
Information/BNI/downloads/RevisedImportantMessageFromMedicare05_2007.pdf).  The 
facility inserts its Quality Improvement Organizations (QIO) name, address, and phone 
number.  It provides this notice to each Medicare patient or the patients representative.  
The CMS does not supply copies of the notice. 
  Upon admission of a Medicare beneficiary to an institution that bills Medicare, or as soon 
thereafter as practical, the provider must verify a patients eligibility in order to process 
the bill.  The provider may obtain this eligibility information directly from the patient or 
through the providers A/B MAC (A)s limited Medicare eligibility data.  See 30.6.  The 
provider contacts its A/B MAC (A) to obtain technical instructions regarding how this 
access may be implemented along with hardware/software compatibility details. 
 
This information does not represent a definitive eligibility status.  If the individual is not 
on file, the provider uses the usual admission and billing procedure in effect, independent 
of this data access. 
 
Disclosure of CMS eligibility data is restricted under the provisions of the Privacy Act of 
1974.  This information is confidential, and may be used only for verifying a patients 
eligibility to benefits under the Medicare program.  Penalties for misuse by anyone may 
result in being found guilty of a misdemeanor and paying a fine not more than $5,000. 
 
10.1 - Medicare beneficiary identifiers                                                       
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
The CMS maintains the electronic records for individuals enrolled in the health insurance 
program.  The CMS issues health insurance cards where entitlement is established 
through the Social Security Administration (SSA), and the Railroad Retirement Board 
(RRB) issues health insurance cards where entitlement is established through RRB. 
 
See Chapter 2 of the Medicare General Information, Eligibility, and Entitlement Manual 
(Pub. 100-01) for an extended discussion of HI cards and Medicare beneficiary 
identifiers. 
                                                                  
10.1.1 - Changes to Medicare beneficiary identifier  
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes.   
Changes in an individuals entitlement to Medicare benefits may result in an individual 
being assigned a completely different HICN.  For example, an individual not entitled to 
monthly benefits (000-00-0000T) marries and becomes entitled to wifes benefits on her 
husbands account (111-11-1111B).  If a claim is submitted under the old HICN, the 
Common Working File (CWF) disposition code 51 will notify the A/B MAC (A), (B), 
(HHH), or DME MAC (whom we will refer to as the MAC when all are meant) of the 
new HICN.  The MAC will annotate its records and use the new HICN when submitting 
future bills or claims. 
 
10.1.2 - Contractor Procedures for Obtaining Missing or Incorrect 
Medicare beneficiary identifiers  
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
Upon receipt of a claim or other paper on which the Medicare beneficiary identifier is 
omitted, incomplete, inconsistent, or obviously incorrect, the MAC submits the claim to 
CWF with the best information it has available.  Depending on the CWF reply, the MAC 
follows the instructions in Chapter 27 for handling various disposition codes, trailers, and 
error codes. 
 
10.1.3 - Importance of Medicare beneficiary identifiers                               
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
The Medicare beneficiary identifier is used in Medicare records to identify the 
beneficiary.  The provider or supplier obtains this number before billing.  See 30 below 
for a description of appropriate processes for obtaining the Medicare beneficiary 
identifier. 
 
10.2 - Prohibition Against Waiver of Health Insurance Benefits as a 
Condition of Admission 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16)   
Providers may not require, as a condition of admission or treatment, that a patient agree 
to waive the right to have services paid for under Medicare.  Requiring such a waiver is 
inconsistent with the agreement with CMS, and the waiver is not binding upon the 
patient.  Providers have agreed not to charge an individual (except for specified 
deductible and coinsurance amounts) for services for which such individual is entitled to 
have payment made or for which he/she would be entitled if the provider complied with 
the procedural and other requirements of the program.  Further, under this provision, the 
provider must refund any amounts incorrectly collected. 
 
Where a patient who has signed such a waiver, nevertheless, requests payment under the 
program, the provider must bill the A/B MAC (A) and refund any payments made by the 
patient, or on the patients behalf, in excess of permissible charges. 
 
10.3 - Requiring Prepayment as a Condition of Admission is Prohibited 
(Rev. 1, 10-01-03) 
HO-303, SNF-317 
 
Providers must not require advance payment of the inpatient deductible or coinsurance as 
a condition of admission.  Additionally, providers may not require that the beneficiary 
prepay any Part B charges as a condition of admission, except where prepayment from 
non-Medicare patients is required.  In such cases, only the deductible and coinsurance 
may be collected.  Where the patient does not have Part B entitlement, the provider will 
follow the rules in 10.6. 
 
10.4 - When Prepayment May Be Requested 
(Rev. 1, 10-01-03) 
HO-303.2 
 
The provider may collect deductible or coinsurance amounts only where it appears that 
the patient will owe deductible or coinsurance amounts and where it is routine and 
customary policy to request similar prepayment from non-Medicare patients with similar 
benefits that leave patients responsible for a part of the cost of their hospital services.  In 
admitting or registering patients, the provider must ascertain whether beneficiaries have 
medical insurance coverage.  Where beneficiaries have medical insurance coverage, the 
provider asks the beneficiary if he/she has a Medicare Summary Notice (MSN) showing 
his/her deductible status.  If a beneficiary shows that the Part B deductible is met, the 
provider will not request or require prepayment of the deductible. 
 
Except in rare cases where prepayment may be required, any request for payment must be 
made as a request and without undue pressure.  The beneficiary (and the beneficiarys 
family) must not be given cause to fear that admission or treatment will be denied for 
failure to make the advance payment. 
 
Providers must insure that the admitting office personnel are informed and kept fully 
aware of the policy on prepayment.  For this purpose, and for the benefit of the provider  and the public, it is desirable that a notice be posted prominently in the admitting office 
or lobby to the effect that no patient will be refused admission for inability to make an 
advance payment or deposit if Medicare is expected to pay the hospital costs. 
 
10.5 - Hospital and Skilled Nursing Facility (SNF) Verification of Prior 
Hospital Stay Information for Determining Deductible and Benefit 
Period Status 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
If it has been determined that Medicare is the primary payer, the hospital or SNF must 
determine if the patient has been an inpatient in any hospital or SNF, including swing bed 
stays, during the prior 60 days.  If so, the hospital or SNF must determine the admission 
and discharge dates and the number of days of hospitalization or skilled nursing (as 
applicable) the patient used in the current benefit period.  The admission and discharge 
dates must be reported on the claim, and the number of days of hospitalization or skilled 
nursing (as applicable) must be used to calculate the hospital insurance copayment and 
the number of days remaining in the benefit period. 
 
If the patient indicates he/she was not an inpatient within the last 60 days, the hospital 
applies the inpatient deductible to the current stay if it is a covered hospital admission.  
The A/B MAC (A) determines the accuracy of the claim data after receipt of the claim.  
The remittance advice received from the A/B MAC (A) reflects the amount of deductible 
(hospital claims) and coinsurance (hospital and SNF claims) applied.  If this amount is 
different from what was billed, the hospital/SNF must correct the records accordingly. 
 
10.6 - Hospitals May Require Prepayment for Noncovered Services 
(Rev. 1, 10-01-03) 
HO-303.3 
 
With regard to noncovered services (e.g., personal comfort items, a private duty nurse), 
the hospital may deny such services for which the beneficiary has not paid or offered 
satisfactory assurance of payment if that is the hospitals practice with nonbeneficiary 
patients.  For example, a private room or TV set need not be furnished to a patient who 
requests it but is unable to prepay or offer the assurance of payment which is usually 
required. 
 
Where the individual has exhausted his/her covered inpatient hospital benefits, or cannot 
supply satisfactory evidence of entitlement under Part A, providers are free to apply to 
such persons the hospitals usual policy with respect to requiring prepayment or other 
assurance of payment where the patient has no insurance.  In addition, for the 
beneficiaries receiving covered inpatient services who are not enrolled for medical 
insurance (Part B), the hospital can apply its usual policy on prepayment or assurance of 
payment with regard to services of salaried physicians provided. 
 
10.7 - Compliance With Agreement  (Rev. 1, 10-01-03) 
HO-303.4 
 
Providers must conform to the policy set forth in this instruction.  Noncompliance will be 
considered in determining whether the provider is honoring its agreement, under which it 
may not charge for services for which payment may be made under the Medicare 
program. 
 
10.8 - Request for Payment Should Be Obtained in All Cases as 
Protective Application for Hospital Insurance Benefits 
(Rev. 1, 10-01-03) 
HO-266, HO-307, SNF-407 
 
To become entitled to HI benefits, an individual must not only be eligible, but must also, 
prior to death, have filed an application for such benefits (or for monthly social security 
benefits).  Even though the individual meets all eligibility requirements, if the individual 
does not file the necessary application before death, the individual cannot become 
entitled, and no payment can be made for hospital services.  The provider should obtain a 
written request for title XVIII payment, filed by or on behalf of a patient, upon admission 
as described in Chapter 1. 
 
Occasionally, a Medicare eligible patient age 65 or over who is admitted to a hospital, 
has never applied for benefits.  A request for payment will protect the eligible patient, the 
patients estate, and the provider against the possibility that timely application will not be 
filed.  If the patient refuses to sign the request, the provider will respect the patients 
wishes.  The provider may then require the patient to pay or give assurance of payment in 
accordance with customary practice for non-beneficiaries.  If the patient cannot sign, and 
is not accompanied by anyone who can sign on the patients behalf, an authorized 
provider official may execute the request for payment on the patients behalf.  The 
admission record containing the request should contain the patients name and be signed 
and dated as of the signature date. 
 
Where the Social Security Office (SSO), upon the providers inquiry for a claim number, 
finds that an apparently eligible inpatient has not applied for benefits; and that the filing 
date established by the written request might permit payment (not otherwise possible) for 
the individuals inpatient services; the SSO will ask the provider for a photocopy of the 
admission record containing the signed request.  The SSO may ask the provider to file a 
prescribed application for benefits on behalf of the patient who is incompetent if there is 
no other qualified applicant. 
 
In the case of a deceased patient, who prior to death signed a document that protected the 
filing date, a provider may apply on behalf of the patient if no other qualified applicant 
applies within six months of the date of notice of the need for application.  However, 
where a qualified survivor or representative of the estate refuses to file and states in 
writing that his/her refusal is based upon the fact that filing would be detrimental to the  deceaseds estate, hospital insurance entitlement cannot be established and payment 
cannot be made for services. 
 
10.9 - A/B MAC (A), (B), or (HHH), or DME MAC Requests to Verify 
Patients Medicare beneficiary identifier                                                  
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
Where the name and Medicare beneficiary identifier information on a claim does not 
match the CMS central record, the A/B MAC (A), (B), or (HHH), or DME MAC will 
return the claim to the provider and request the provider to verify the information. 
 
The provider will compare the name and number on the claim with that on provider 
records.  If the information submitted was incorrect, the provider will return the claim to 
the MAC with the corrected information. 
 
If, however, the information in the providers records identifying the patient is the same 
as the information submitted on the claim, the provider will contact the SSO for 
assistance. 
 
10.10 - A/B MAC (A), (B), or (HHH) or DME MAC Learns Beneficiary 
is an HMO Enrollee 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
If the A/B MAC (A), (B), or (HHH), or DME MAC determines from its records or its 
query to CMS that a patient is an HMO enrollee, the MAC will return the claim to the 
provider with instructions to request payment from the HMO for payment, if appropriate. 
 
10.11 - Retroactive Entitlement 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
When an application for social security benefits is filed by a person 65 years of age or 
older, the person may inform the SSO that he/she received hospital services in the 
retroactive period of up to six months for which he/she may be entitled to benefits.  In 
these cases, the provider may bill for covered retroactive services but must verify the 
patients eligibility through the A/B MAC (A), (B), or (HHH), or DME MAC before  billing.  If the patient paid, the provider must refund the appropriate amount to the 
patient. 
 
10.12 - SNF Verification of Prior Hospital Stay and Transfer 
Requirements 
(Rev. 1, 10-01-03) 
SNF-414 
 
SNFs must verify that the beneficiary was discharged from a hospital with a transfer 
agreement with the SNF and that: 
 
a.  The date of discharge is on or after the first day of the month in which the 
beneficiary became entitled to Medicare; 
 
b.  The hospital stay was at least three calendar days in duration (hospital days to 
which waiver of liability was applied cannot be used to satisfy the 3-day 
requirement); and 
 
c.  The 3-day qualifying stay was within 30 days of the SNF admission, unless the 
rules for exception apply. 
 
The hospital usually sends the SNF a patient transfer form or other record in accordance 
with the transfer agreement.  The dates of the hospital stay are required on the claim. 
 
For more information on the above criteria, see Chapter 8 of the Medicare Benefit Policy 
Manual. 
 
20 - Obtaining Information to Determine Whether to Bill Medicare or 
Another Payer 
(Rev. 1, 10-01-03) 
HO-300, SNF-401 
 
The provider must ascertain whether the patient is a member of a Medicare + Choice 
organization (M+CO).  If the patient is a member of an M+CO, the provider must contact 
the M+CO specified by the patient or identified on the patients membership card, so the 
provider may determine whether to submit the claim to the M+CO. 
 
If the patient indicates that he/she is not a member of an M+CO, the provider, in order to 
determine whom to bill, develops for situations where Medicare is the secondary payer 
by obtaining answers to the Admission Questions to Ask Medicare Beneficiaries 
contained in Chapter 3 of the Medicare Secondary Payer Manual.  If another insurer is 
identified as primary to Medicare, the provider follows the procedures in the Medicare 
Secondary Payer (MSP) Manual. 
 
20.1 - Provider Development of Medicare Secondary Payer 
(Rev. 1, 10-01-03)  HO-301, SNF-401, A-03-031 
 
Medicare is the secondary payer under certain circumstances.  See Medicare Secondary 
Payer (MSP) Manual, Chapter 1, for related instructions. 
 
30 - Provider/Supplier Obtaining/Verifying the Medicare beneficiary 
identifier and Entitlement Status 
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
It is important that the patients Medicare beneficiary identifier be obtained and 
accurately recorded because the claim cannot be processed if the Medicare beneficiary 
identifier is missing or incorrect. A social security number is not sufficient. 
 
When a patient 65 years of age or over, or a younger patient who possibly has entitlement 
to Medicare as a disability beneficiary or under the provisions for coverage of persons 
needing a kidney transplantation or dialysis, is admitted or registered for services, the 
provider asks for the health insurance card, Temporary Notice of Medicare Eligibility, or 
other notice the patient has received from CMS or an A/B MAC (A), (B), (HHH), or 
DME MAC which shows the Medicare beneficiary identifier.  If a patient or prospective 
patient is within three months of age 65, or is disabled or has ESRD, and has not applied 
for HI entitlement, the provider advises the patient to contact the SSO, or to have 
someone do so on the patients behalf.  The provider may arrange with the SSO to 
routinely bring such cases to the SSOs attention. 
 
This requirement also applies to inpatient services for which no payment is due because 
providers are required to submit inpatient claims even when benefits are exhausted or are 
not payable for some reason.  The CMS requires this data to record necessary benefit 
information on CMS records.  Where the patient refuses to request payment and refuses 
to furnish information about his/her Medicare beneficiary identifier, the provider 
documents the records accordingly and attempts to get the Medicare beneficiary 
identifier from the SSO. 
 
30.1 - Cross-Reference of Medicare Beneficiary Identifier                      
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and  the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
If a beneficiarys entitlement to Medicare has been transferred from one Medicare 
beneficiary identifier to another, the CWF will cross-reference the old number to the new 
number.  If there has been utilization of benefits under each number, all data will be 
combined under the new number. 
 
A. Disposition Code 51 
 
1. If, after submitting the admission notice or Part B claim to CMS, the MAC receives 
a disposition code of 51 with trailer code 01 containing a possible Medicare 
beneficiary identifier, the MAC investigates the new Medicare beneficiary 
identifier, and if it believes the new Medicare beneficiary identifier is correct, the 
MAC resubmits the claim under the new Medicare beneficiary identifier.  CWF 
responds with an appropriate disposition code and any associated trailers for 
processing the claim. 
 
2. If the MAC receives a disposition code of 51 without trailer code 01, or after 
investigation determines the Medicare beneficiary identifier in the 01 trailer is 
incorrect, it denies the claim using the following message: 
 
Payment cannot be made for the services you received from (name 
of provider) because we have no record of your Medicare 
beneficiary identifier.  Please write your correct number on the 
claim and resubmit the claim to (name of provider).  If you think 
the number is right, check with your local Social Security Office. 
 
B. Disposition Code 55 
 
If CWF returns disposition code 55 and trailer code 08 containing an error code of 5052, 
indicating a mismatch in the beneficiarys personal characteristics, CWF will also return 
to the MAC what it believes to be the proper information on trailer code 10.  The header 
portion of the response also contains the corrected sex and birth date, if applicable, of the 
beneficiary. 
 
The MAC investigates the information provided, corrects the information on the claim, 
and resubmits it to CWF.  If the MAC continues to receive a code 55, it contacts the Host 
through locally established procedures.  See Chapter 27. 
 
30.2 - Health Insurance (HI) Card 
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare  beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
As part of health insurance electronic data processing, HI cards are issued by CMS (or by 
the RRB where railroad retirement beneficiaries are involved) to individuals who have 
established entitlement to health insurance.  (See Chapter 2 of the Medicare General 
Information, Eligibility, and Entitlement Manual.)  The health insurance card is used to 
identify the individual as being entitled and serves as a source of information required to 
process Medicare claims or bills.  The health insurance card displays the beneficiarys 
name, sex, Medicare beneficiary identifier, and effective date of entitlement to hospital 
insurance and/or medical insurance. 
 
If any MAC receives an inquiry about replacing a lost or destroyed HI card, it informs the 
inquirer to get in touch with the SSO nearest the inquirers address for assistance.  SSO 
addresses are generally listed in local telephone directories under Social Security 
Administration. 
 
A health insurance card is acceptable without a signature, but the provider will ask the 
patient to sign it. 
 
30.3 - Temporary Eligibility Notice 
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
The SSO may issue a temporary health insurance eligibility notice, pending the issuance 
of a health insurance card, when the beneficiary is in need of immediate medical services.  
The provider may obtain the patients name and Medicare beneficiary identifier from the 
temporary eligibility notice.  See Chapter 2 of the Medicare General Information, 
Eligibility, and Entitlement Manual for an example of the temporary notice. 
 
For claims processed by the A/B MAC (B) or DME MAC, the individual, the 
individuals physician, or other supplier must show the Medicare beneficiary identifier on 
the request for Medicare payment and on other related bills and documents.  Because 
Health Insurance records are maintained by the individuals Medicare beneficiary 
identifier, the Medicare beneficiary identifier must be used on all communications. 
claim number, the claim number must be used on all communications. 
 
  30.4 - Certificate of Social Insurance Award 
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
Health insurance beneficiaries receive a Certificate of Social Insurance Award, SSA-30, 
showing the Medicare beneficiary identifier, dates of entitlement to Part A and/or Part B 
benefits, and the following statement: 
 
This notice may be used if Medicare services are needed before you receive 
your health insurance card. 
 
30.5 - Medicare Summary Notice (MSN) 
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
If patients cannot furnish their health insurance cards when admitted, they may have a 
MSN form showing the Medicare beneficiary identifier.  A notice is mailed to a 
beneficiary shortly after Part A or Part B benefits have been paid on the beneficiarys 
behalf.  Deductible status is also shown on these forms. 
 
30.6 - Provider Access to CMS and A/B MAC (A) or (HHH) Eligibility 
Data 
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
The A/B MAC (A) or (HHH) will allow only Medicare certified providers as defined in 
1861 and 1866(e) of the Social Security Act (the Act) and their billing agents 
automated access to beneficiary eligibility data.  Disclosure of CWF eligibility data is  restricted under provisions of the Privacy Act of 1974, 5 U.S.C 552a.  Under limited 
circumstances, the Privacy Act permits CMS to disclose information without consent of 
the individual.  One circumstance is for routine uses, that is, disclosure for purposes 
that are compatible with the purpose for which CMS collects the information.  In the case 
of this provider access, a routine use exists which permits release of data to providers or 
their authorized billing agents for the purpose of verifying a patients eligibility for 
benefits under the Medicare program.  The use of the data by a provider in preparing 
claims for hospital-based physicians would be an example of unauthorized use because 
the physicians are not Medicare providers as defined in the Act. 
 
A/B MACs (A) or (HHH) will adjust their systems to accept the revised standard 
HIQA/HUQA records from the CMS CWF.  The standard data elements to be made 
available to providers are listed below: 
 
  Medicare beneficiary identifier; 
 
  Beneficiary: 
 
  Last name (first six positions)/first initial; 
o
 
  Date of birth; 
o
 
  Sex; 
o
 
  Date of death; 
o
 
  Lifetime reserve days remaining; 
o
 
  Lifetime psychiatric days remaining (requesting hospital must use a 
o
psychiatric provider number to obtain this data); 
 
  Cross reference Medicare beneficiary identifier; 
o
 
  Current and prior A and B entitlements, with start and stop dates for Part A, 
o
Part B, ESRD, HMO, and hospice; and 
 
  Spell of illness (applicable spell based on the date entered by the provider and 
o
the next most recent spell): 
 
  Hospital full days remaining; 
 
  Hospital coinsurance days remaining; 
 
  SNF full days remaining; 
 
  SNF coinsurance days remaining;   
  Part A cash deductible remaining to be met; 
 
  Date of earliest billing action for indicated spell-of-illness; 
 
  Date of latest billing action for indicated spell-of-illness; 
 
  Blood deductible (combined annual Part A and B remaining to be 
met for applicable year entered by provider); 
 
  Part B trailer year (applicable year based on date entered by 
provider); 
 
  Part B cash deductible; 
 
  Physical therapy/speech-language pathology limit (physical 
therapy and speech-language pathology are applicable to physical 
therapy limit); 
 
  Occupational therapy limit; 
 
  Hospice data (applicable periods based on the date entered by the 
provider and the next most recent period); 
 
  ESRD indicator (shows beneficiary is currently entitled); 
 
  REP payee indicator; 
 
  MSP indicator; 
 
  Home Health Benefit Period: 
 
  Part A visits remaining; 
o
 
  Part B visits applied; 
o
 
  Date of earliest billing action for home health benefit period; 
o
 
  Date of latest billing action for home health benefit period. 
o
 
  HMO information (applicable periods based on date entered by the 
provider): 
 
  Name; 
o
 
  Identification number; 
o  
  ZIP Code; 
o
 
  Option code; 
o
 
  Start date; 
o
 
  Termination date; 
o
 
  Pap smear screening risk indicator, professional date, and 
o
technical date; 
 
  Mammography screening risk indicator (applicable to 
o
screening services prior to January 1, 1998), professional date, 
and technical date; 
 
  Colorectal screening (no risk indicator); procedure code, 
o
professional date, and technical date; 
 
  Pelvic screening risk indicator and professional date; 
o
 
  Pneumococcal pneumonia vaccine (PPV) date; 
o
 
  Influenza virus vaccine date; and 
o
 
  Hepatitis B vaccine date. 
o
 
See Chapter 10 of this manual for a complete discussion of the HIQH (Health Insurance 
Query for Home Health Agencies). 
 
The A/B MAC (A) will make sure that psychiatric information is not being made 
available to all hospitals.  This information is to be made available only to psychiatric 
hospitals or hospitals that furnish inpatient psychiatric hospital services. 
 
Providers may use direct entry terminals or dial-up terminals to inquire about beneficiary 
eligibility utilization and deductible status.  The A/B MAC (A) must use either the HIQA 
screen display (see 30.6.1.1) or create its own Customer Information Control System 
(CICS) screens from the HUQA data records (see 30.6.1.2 and 30.6.1.3).  Providers 
may not have access to any other CWF records, e.g., the health insurance master record 
(HIMR).  The data must be from CWF.  The A/B MAC (A) will not substitute local 
history. 
 
30.6.1 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
  30.6.1.1 - Part A Inquiry (HIQA) Screen Display 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
All the data elements are explained in full for proper use.  A/B MACs (A) or (HHH) 
should access this screen to transmit data to their providers and suppliers when supplying 
data for 30.6.1.2. 
 
30.6.1.2 - Part A Inquiry Reply (HIQAR) Screen Display 
(Rev. 1, 10-01-03) 
A3-3508.4 
 
This screen format can be used to pass beneficiary entitlement and utilization data to the 
provider.  It is described in the CWF Documentation, Chapter VII, Section H, pages 1 
through 24.  Refer to the CWF Documentation when providing utilization data to the 
provider. 
 
30.6.1.3 - Part A Inquiry (HUQA) Data 
(Rev. 1, 10-01-03) 
A3-3508.5 
 
This transaction may be used to obtain the HUQA dataset.  (See 30.6.)  Also, refer to 
Chapter II of the CSC maintained CWF Documentation. 
 
30.6.1.4 - Part A Inquiry Reply (HUQAR) Data 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
This response can be used to create the A/B MAC (A)s or (HHH)s own screens to 
return beneficiary eligibility and utilization data to providers. 
 
30.6.1.5 - Health Insurance Query for Home Health Agencies (HIQH) 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
This transaction, which is available through A/B MAC (HHH) remote access, is used by 
HHAs to ascertain whether an episode has been opened for a given beneficiary by 
another provider (who is the primary HHA) and to track episodes for beneficiaries for 
whom the inquiring HHA is the primary HHA. 
 
30.6.2 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
  30.6.3 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.6.4 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.6.5 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.6.6 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.8 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.10 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.11 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.12 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.13 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.14 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.15 - Reserved  (Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.16 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.17 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.18 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.19 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.19.1 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.19.2 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.19.3 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.19.4 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.20 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
30.21 - Requesting Assistance in Resolving Problem Areas in the 
Inquiry/Inquiry Response Procedures 
(Rev. 1, 10-01-03) 
A3-3523, 3-6008 
 
See 70.   
30.21.1 - HMO-Related Master File Corrections 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
The A/B MAC (A), (B), or (HHH), or DME MAC will fully document and send to the 
HMO inquiries concerning problems with HMO data on the HI Master.  The HMO will 
resolve the problem and advise the contractor of the results. 
 
30.22 - Provider Problems Obtaining Entitlement Information 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
If after application of the above procedures, the provider encounters significant problems 
in obtaining information regarding Medicare entitlement or benefits in order to accurately 
prepare bills, the provider should contact the A/B MAC (A), (B), or (HHH), or DME 
MAC for assistance.  However, these requests should be on a non-routine basis.  The 
MAC will assist providers in obtaining entitlement information.  The MAC may 
temporarily refuse assistance if a pattern of abuse is discovered.  Situations that may 
require MAC assistance are: 
 
  When the patient dies following admission.  It may be necessary to file timely 
with an estate; 
 
  When the patient is not in a physical or mental condition to discuss his/her 
entitlement, and no other person with knowledge of the patients affairs is 
available; 
 
  When the provider has reason to believe the beneficiary may need lifetime reserve 
days, and his/her signature must be obtained if the available lifetime reserve days 
are not to be used for this admission and other financial arrangements must be 
made; 
 
  When it is suspected that the beneficiary may have exhausted his/her Medicare 
benefits, and timely confirmation is needed in order to file for possible 
supplemental benefits; and  
 
  When the patient has experienced repeated admissions during the same spell of 
illness, and determining available benefits for the beneficiary is difficult. 
 
50 - Critical Case Procedures - Establishing Entitlement Under Part A 
and B 
(Rev. 1, 10-01-03) 
 
See Chapter 27.   
60 - Reserved  
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
60.1 - Reserved  
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
60.2 - Reserved  
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16). 
 
70 - SSO Assistance in Resolving Entitlement Status Problems 
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
A. Social Security Office (SSO) Assistance 
 
The A/B MAC (A), (B), or (HHH), or DME MAC directs initial requests for assistance to 
the SSO if the problem is caused by difficulties in determining the beneficiarys correct 
entitlement status.  Examples of situations that may require SSO assistance are: 
 
  Problems involving Railroad Retirement Board (RRB) jurisdiction; 
 
  Evidence that a beneficiary has utilization under more than one Medicare 
beneficiary identifier but there is no awareness of any cross-reference action taken 
by CMS; or 
 
  The beneficiarys name, address, sex code, date of birth, or date of death is 
incorrect on the HI master record. 
 
In the event the SSO is unable to resolve the entitlement problem (e.g., cross referencing 
of HI records), the MAC requests assistance from the RO. 
 
90 - Outpatient Hospital Registration Procedures 
(Rev. 1, 10-01-03) 
HO-350 
  90.1 - Patient Identification 
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19) 
 
The term Medicare beneficiary identifier (Mbi) is a general term describing a 
beneficiary's Medicare identification number. For purposes of this manual, Medicare 
beneficiary identifier references both the Health Insurance Claim Number (HICN) and 
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition 
period and after for certain business areas that will continue to use the HICN as part of 
their processes. 
 
Upon registration of a Medicare beneficiary, or as soon thereafter as practical, the 
hospital will ask the patient for his/her health insurance card to obtain the Medicare 
beneficiary identifier.  If the patient is unable to provide it, the hospital will contact the 
SSO for assistance. 
 
90.2 - Determining Whom to Bill 
(Rev. 1, 10-01-03) 
HO-350.B 
 
The procedures for determining whether another payer exists are the same for outpatient 
situations as for inpatient.  Therefore, the hospital will follow 20 for developing other 
coverage. 
 
90.3 - Source of Admission - Outpatient Hospital 
(Rev. 1472, Issued: 03-06-08, Effective: 05-23-07, Implementation: 04-07-08) 
 
The hospitals registration process must distinguish whether the referral source for this 
registration/admission is from: 
 
  Its own inpatient hospital; 
 
  An encounter in another hospital (see 90.6 for definition of encounter); or 
 
  Any other source - See chapter 25. 
 
Hospitals must determine the appropriate source of admission from internal records or by 
asking the patient who referred him/her, and whether the referral took place as a result of 
an encounter in the servicing hospital, another hospital, or elsewhere. 
 
The following coding must be used on the outpatient claim.  Therefore 
admission/registration processes must obtain the information. 
 
1.  Physician Referral - The patient was referred to this facility for outpatient or 
referenced diagnostic services by his/her personal physician, or the patient 
independently requested outpatient services (self-referral). 
  2.  Clinic Referral - The patient was referred to this facility for outpatient or 
referenced diagnostic services by this facilitys clinic or other outpatient 
department physician. 
3.  HMO Referral - The patient was referred to this facility for outpatient or 
referenced diagnostic services by an HMO physician. 
 
4.  Transfer from a Hospital - The patient was referred to this facility for outpatient 
or referenced diagnostic services by a physician of another acute care facility. 
 
5.  Transfer from a SNF - The patient was referred to this facility for outpatient or 
referenced diagnostic services by a physician of the SNF where the patient is an 
inpatient. 
 
6.  Transfer from Another Health Care Facility - The patient was referred to this 
facility for outpatient or referenced diagnostic services by a physician of another 
health care facility where the patient is an inpatient. 
7.  Emergency Room - The patient was referred to this facility for outpatient or 
referenced diagnostic services by this facilitys emergency room physician. 
 
8.  Court/Law Enforcement -The patient was referred to this facility for outpatient or 
referenced diagnostic services upon the direction of a court of law, or upon the 
request of a law enforcement agency representative. 
 
9.  Information not available. 
 
10. Transfer from a CAH - The patient was referred to this facility for outpatient or 
referenced diagnostic services by (a physician of) the CAH were the patient is an 
inpatient. 
 
The hospital must determine the proper source of admission code based on the patients 
response and/or any other information the hospital may have available from its 
preregistration records or scheduling data.  The hospital must enter the proper source of 
admission code on the claim. 
 
NOTE:  Information regarding the form locator number that corresponds to the source of 
admission code and a table to crosswalk its CMS-1450 form locator to the 837 
transaction is found in Chapter 25. 
 
If the patient was referred for services by a physician at: 
 
  This hospital, the hospital enters codes 2 or 7; 
 
  Another hospital, the hospital enters code 4; or 
 
  Some other source, the hospital enters codes 1, 3, 5, 6, 8, 9, or A, as appropriate. 
  If the hospital is sure the admission source is not from its hospital or another hospital but 
cannot determine which of the codes apply, the hospital will enter code 1 on Medicare 
claims.  However, incorrect reporting where services were referred by staff at its own 
hospital or another hospital (codes 2, 4, or 7 are applicable) is considered program abuse 
and subject to applicable sanctions. 
 
90.4 - Type of Bill 
(Rev. 2971, Issued: 05-23-14, Effective: 07-01-14, Implementation, 07-07-14) 
 
To properly bill, hospitals other than CAHs assign type of bill (TOB) 13X to all bills for 
outpatient hospital services and TOB 14X for non-patient (referred) laboratory 
specimens.  A non-patient is defined as a beneficiary that is neither an inpatient nor an 
outpatient of a hospital, but that has a specimen that is submitted for analysis to a hospital 
and the beneficiary is not physically present at the hospital. 
 
TOB 14X should only be billed for non-patient lab specimens, which are paid under the 
clinical laboratory fee schedule at the lesser of the actual charge, the fee schedule 
amount, or the National Limitation Amount (NLA), (including CAHs and MD Waiver 
hospitals).  Part B deductible and coinsurance do not apply for laboratory tests payable on 
the laboratory fee schedule. 
 
TOB 14X should no longer be used for referred diagnostic services other than laboratory 
services. 
 
CAHs should bill TOB 85X for outpatient services (including outpatient labs), and TOB 
14X for non-patient laboratory specimen tests. 
 
90.5 - Definition of Diagnostic Services 
(Rev. 1, 10-01-03) 
HO-350.E 
 
A service is diagnostic if it is an examination or procedure to which the patient is 
subjected, or which is performed on materials derived from a hospital outpatient to obtain 
information to aid in the assessment of a medical condition or the identification of a 
disease.  Among these examinations and tests are diagnostic laboratory services such as 
hematology and chemistry, diagnostic x-rays, isotope studies, EKGs, pulmonary function 
tests, psychological tests, and other tests given to determine the nature and severity of an 
ailment or injury.  Hospitals may determine whether services are diagnostic from their 
internal systems as appropriate. 
 
90.6 - Definition of Encounter 
(Rev. 1, 10-01-03) 
HO-350F 
 
The term encounter means a direct personal contact in the hospital between a patient 
and a physician, or other person who is authorized by State law and, if applicable, by  hospital staff bylaws to order or furnish services for diagnosis or treatment of the patient.  
Direct personal contact does not include telephone contacts between a patient and 
physician.  Nor is the compensation arrangement between the physician and the hospital 
relevant to whether an encounter has occurred.  Patients will be treated as hospital 
outpatients for purposes of billing for certain diagnostic services that are ordered during 
or as a result of an encounter that occurred while such patients are in an outpatient status 
at the hospital.  If a Medicare outpatient is referred to another provider or supplier for 
further diagnostic testing or other diagnostic services as a result of an encounter that 
occurs in this hospital, the hospital is responsible for arranging with the other entity for 
the furnishing of services.  Hospitals are not required to verify that all ordered services 
are furnished but only to assure that, when it is necessary to refer a patient to an outside 
entity, the referral is made to a provider or supplier with which the referring hospital an 
arrangement.  This requirement is necessary to assure that billing for services that are 
furnished is processed through the servicing hospital. 
 
When a patient has follow-up visits with a physician in the hospital following an initial 
encounter, each subsequent visit to the physician will be treated as a separate encounter 
for billing. 
 
100 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
100.1 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
110 - ESRD Method Selection 
(Rev. 1, 10-01-03) 
 
See chapter 8, for instructions for completing the ESRD Method Selection Form. 
 
110.1 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
 
120 - Reserved 
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC 
Implementation: 02-16-16; ASC X12: 02-16-16) 
  Transmittals Issued for this Chapter 
Rev #  Issue Date  Subject  Impl Date  CR# 
R4247CP  03/01/2019  Update to Publication 100-04 Chapters  04/01/2019  11155 
2, 6, and 18 to Provide Language-Only 
Changes for the New Medicare Card 
Project 
R3441CP  01/15/2016  Update to Pub. 100-04, Chapter 02  02/16/2016  9457 
Admission and Registration 
Requirements, for Provider Verification 
of Beneficiary Eligibility and 
Entitlement 
R2971CP  05/23/2014  July 2014 Update of the Hospital  07/07/2014  8776 
Outpatient Prospective Payment System 
(OPPS) 
R1472CP  03/06/2008  Update of Institutional Claims  04/07/2008  5893 
References 
R1421CP  01/25/2008  Update of Institutional Claims  04/07/2008  5893 
References  Rescinded and Replaced 
by Transmittal 1472 
R1257CP  05/25/2007  Important Message From Medicare (IM)  07/02/2007  5622 
and Expedited Determination 
Procedures for Hospital Discharges 
R980CP  06/14/2006  Changes Conforming to CR 3648  10/02/2006  4014 
Instructions for Therapy Services - 
Replaces Rev. 941 
R941CP  05/05/2006  Changes Conforming to CR 3648  10/02/2006  4014 
Instructions for Therapy Services  
R851CP  02/10/2006  Revisions to Instructions for Contractors  05/11/2006  4218 
Other Than the Religious Nonmedical 
Health Care Institutions Specialty 
Contractor Regarding Claims for 
Beneficiaries with RNCHI Elections 
R795CP  12/30/2005  Redefined Type of Bill 14X For Non- 04/03/2006  4208 
Patient Laboratory Specimens-CR 3835 
Manualization  R001CP  10/01/2003  Initial Publication of Manual  NA  NA 
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