Medicare Claims Processing Manual 
Chapter 1 - General Billing Requirements 
Crosswalk 
Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  01          Foreword 
1  10          Jurisdiction for Claims 
1  10.1    B3-3100      Carrier Jurisdiction of Requests for Payment 
1  10.1.1    B3-3100.1,      Area Carrier Physician's Services 
B3-3101,  
B4-2010 
partial,  
B3-4267, 
R1813B3 
1  10.1.2          Physician, Supplier, and Group Practice Billing for Multiple 
Locations 
1  10.1.3    B3-3100.6,      Exceptions to Provider Billing Local Carrier 
R1813B3 
1  10.1.4    B3-2312      Services Received by Medicare Beneficiaries Outside the United 
States 
1  10.1.4.1    B3-2312-      Physician and Ambulance Services Furnished in Connection With 
   2312.2  Covered Foreign Inpatient Hospital Services  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  10.1.4.2    B3-2312.3      Carriers Designated to Process Foreign Claims 
1  10.1.4.3    B3-2312.4      Source of Part B Claims 
1  10.1.4.4    B3-2312.5      Medicare Approved Charges for Services Rendered in Canada or 
Mexico 
1  10.1.4.5    B3-2312.6      Appeals of Denied Charges for Physicians and Ambulance 
Services in Connection With Foreign Hospitalization 
1  10.1.4.6    B3-2312.7      Claims for Services Furnished in Canada and Mexico to Qualified 
Railroad Retirement Beneficiaries 
1  10.1.4.7    B3-2020.1      Shipboard Services Billed to the Carrier 
1  10.1.5    B3-3102,       Domestic Claims Processing Jurisdictions 
B3-3116 
1  10.1.5.1    B3-3116      Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, 
Supplies, Parental and Enteral Nutrition (PEN) 
1  10.1.5.2          Supplier of Portable X-Ray, EKG or Similar Portable Services 
1  10.1.5.3          Ambulance Services Submitted to Carriers 
1  10.1.5.4          Independent Laboratories 
1  10.1.5.4.1          Cases Involving Referral Laboratory Services 
1  10.1.6    B3-3103      Railroad Retirement Beneficiary Carrier  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  10.1.7    B3-3104,       Welfare Carriers 
B3-3060 for 
buy-in 
definition 
1  10.1.8    B3-3105      United Mine Workers of America (UMWA) 
1  10.1.9    B3-3110      Disposition of Misdirected Claims 
1  10.1.9.1          Area Carrier to Another Area Carrier 
1  10.1.9.2    B3-3110      Area Carrier to RRB-Named Carrier 
1  10.1.9.3          RRB-Named Carrier to Area Carrier 
1  10.1.9.4          Area Carrier or RRB-Named Carrier to Welfare Carrier 
1  10.1.9.5          Protests Concerning Transfer of Requests for Payment to Carrier 
or Intermediary 
1  10.1.9.6    B3-3110.1      Transfer of Claims Material Between Carrier and Intermediary 
1  10.1.9.6.1    B3-3110.2      Signature Requirements for Carriers and Intermediaries 
1  10.2          Intermediary Jurisdiction of Requests for Payment 
1  10.2.1          Intermediary Payment for Emergency and Foreign Hospital 
Services 
1  10.3    B3-3115      Payments Under Part B for Services Furnished by Suppliers of 
Services to Patients of a Provider 
1  20  A2-2807.A,       OPT-122  Provider Election of Intermediary 
A3 36004 Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
A3-3600.4 
1  20.1  A2-2807.B        Intermediary Service to HHAs and Hospices 
1  20.2  A2-2807.C        Provider Change of Ownership (CHOW) 
1  20.3  A2-2807.D        Multi-State Provider Chains Billing Intermediaries 
1  20.4  A2.2808        The Process for a Provider to Change an Intermediary 
1  20.5  A2.2809        Intermediary Relationships With Providers Serviced by Another 
Intermediary 
1  20.5.1          Solicitation of a Provider to Secure a Change of Intermediary 
1  20.5.2          Communications 
1  30  A2-2810        Provider Participation 
1  30.1  A2-2840,       RHC-320  Content and Terms of Provider Participation Agreements 
1  30.1.1        RHC-321  Provider Charges to Beneficiaries 
1  30.1.2        RHC-322  Provider Refunds to Beneficiaries 
1  30.1.3        RHC-323  Provider Treatment of Beneficiaries 
1  30.2  A3-3488,  B3-3060      Assignment of Provider's Right to Payment 
A3- 3703.1 
1  30.2.1          Exceptions to Assignment of Provider's Right to Payment - 
Claims Submitted to FIs and Carriers 
1  30.2.2    B3-3045.1      Background and Purpose of Reassignment Rules - Claims 
SubmittedtoCarriers Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
Submitted to Carriers 
1  30.2.2.1  A3-3005        Reassignments by Nonphysician Suppliers - Claims Submitted to 
FIs 
1  30.2.3          Effect of Payment to Ineligible Recipient 
1  30.2.4  A3-3488.1  B3-3060.10      Payment to Agent - Claims Submitted to Carriers 
1  30.2.5  A3-3488.2  B3-3060.11      Payment to Bank 
1  30.2.6    B3-3060.1      Payment to Employer of Physician - Carrier Claims Only - 
Carrier Claims Only 
1  30.2.7    B3-3060.2      Payment to Facility in Which Services Are Performed 
1  30.2.8    B3-3060.3      Carrier Payment to Health Care Delivery System - Claims 
Submitted to Carriers 
1  30.2.8.1    B3-3060.3C      Definition of Health Care Delivery System 
1  30.2.8.2    B3-3060.3D      University-Affiliated Medical Faculty Practice Plans - Claims 
Submitted to Carriers 
1  30.2.8.3    B3-3060.3E,      Managed Care Organization, including HCPPs, Cost-Contracting 
B3-7065  HMOs, CMPs, and Medicare + Choice Organizations - Claims 
Submitted to Carriers 
1  30.2.9    B3-3060.4,      Payment to Physician for Purchased Diagnostic Tests - Claims 
R1813B3  Submitted to Carriers 
1  30.2.9.1    B3-3060.5      Payment to Supplier of Diagnostic Tests for Purchased 
Interpretations  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  30.2.10    B3-3060.6      Payment Under Reciprocal Billing Arrangements - Claims 
Submitted to Carriers 
1  30.2.11    B3-3060.7      Payment Under Locum Tenens Arrangements - Claims Submitted 
to Carriers 
1  30.2.12    B3-3060.8      Establishing That a Person or Entity Qualifies to Receive 
Payment on Basis of Reassignment - for Carrier Processed 
Claims 
1  30.2.13    B3-3060.9      Billing Procedures for Entities Qualified to Receive Payment on 
Basis of Reassignment - for Carrier Processed Claims 
1  30.2.14  A3-3488.3   B3-3060.6E.      Correcting Unacceptable Payment Arrangements 
B3-3060.12 
1  30.2.14.1          Questionable Payment Arrangements 
1  30.2.15  A3-3488.4  B3-3060.13,       Sanctions for Prohibited Payment Arrangement 
B3-3060.14 
1  30.2.16  A3-3488.5  B3-3060.15,       Prohibition of Assignments by Beneficiaries 
B3-7065 partial 
1  30.3  A3-3005  B3-17000      Physician/Practitioner/Supplier Participation Agreement and 
Assignment - Carrier Claims 
1  30.3.1    B3-3040.4      Mandatory Assignment on Carrier Claims 
1  30.3.1.1    B-3040.3      Processing Claims for Services of Participating Physicians or 
Suppliers by Carriers 
1  30.3.2    B3-3045.1      Nature and Effect of Assignment on Carrier Claims  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  30.3.3    B3-3045.2      Physician's Right to Collect from Enrollee on Assigned Claim 
Submitted to Carriers 
1  30.3.4    B3-3045.3      Effect of Assignment Upon Rental or Purchase of Durable 
Medical Equipment on Claims Submitted to Carriers 
1  30.3.5    B3-3045.4      Effect of Assignment Upon Purchase of Cataract Glasses from 
Participating Physician or Supplier on Claims Submitted to 
Carriers 
1  30.3.6    B3-3045.5      Mandatory Assignment Requirement for Physician Office 
Laboratories on Claims Submitted to Carriers 
1  30.3.7    B3-3045.6      Physicians Billing for Purchased Diagnostic Tests (Other Than 
Clinical Diagnostic Laboratory Tests) on Claims Submitted to 
Carriers 
1  30.3.8    B3-3045.7      Mandatory Assignment and Other Requirements for Home 
Dialysis Supplies and Equipment Paid Under Method II on 
Claims Submitted to Carriers 
1  30.3.9    B3-3040      Filing Claims to a Carrier For Nonassigned Services 
1  30.3.10    B3-3040.1      Carrier Submitted Bills by Beneficiary 
1  30.3.11    B3-3040.2      Carrier Receipted Bill - Definition 
1  30.3.12    B3-17001      Carrier Annual Participation Program 
1  30.3.12.1    B3-17001.1      Carrier Participation and Billing Limitations 
1  30.3.12.2    B3-17001.1      Carrier Participation Agreement  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  30.3.12.3    B3-17002      Carrier Rules for Limiting Charge 
1  40  A3-3008,         Termination of Provider Agreement 
A2-2800 
1  40.1  A3-3008.1,      RHC-330,   Voluntary Termination 
A2-2800.1  OPT-124 
1  40.1.1  A2-2800.2      RHC-330  Close of Business 
1  40.1.2        HHA-145,   Change of Ownership 
HO-145;  
SNF-145;  
RHC-331,  
RHC-332 
1  40.1.3  A3-3008.3        Expiration and Renewal-Nonrenewal of SNF Term Agreements 
1  40.2  A3-3008.2      RHC-331  Involuntary Terminations 
1  40.2.1  A2-2800.3        Processing Involuntary Terminations 
1  40.2.2  A2-2801,         Intermediary Report on Provider Deficiencies 
A2-2801.1 
1  40.2.2.1  A2-2801.2        Subsequent Communications With Provider 
1  40.3  A2-2804        Readmission to Medicare Program After Involuntary Termination 
1  40.3.1  A2-2804.1        Effective Date of Provider Agreement 
1  40.3.2  A2-2805      RHC-334  Fiscal Considerations In Provider Readmission To Medicare 
Program After Involuntary Termination  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  40.4  A3-3008.4        Payment for Services Furnished After Termination, Expiration, or 
Cancellation of Provider Agreement 
1  40.4.1  A3-3600.3        Reviewing Inpatient Bills for Services After Suspension, 
Termination, Expiration, or Cancellation of Provider Agreement, 
or After a SNF is Denied Payment for New Admissions 
1  40.4.2  A3-3699.3.C        Status of Hospital or SNF After Termination, Expiration, or 
Cancellation of Its Agreement 
1  40.5  A3-3600.7        Intermediary/Carrier/DMERC Responsibilities for Informing 
Providers of Changes 
1  50  A3-3301        Filing a Request for Payment With the Carrier or Intermediary 
1  50.1  A3-3302        Request for Payment from the Carrier or Intermediary 
1  50.1.1  A3-3302.1,         Billing Form as Request for Payment 
A3-3602.4 
1  50.1.2  A3-3302.2        Beneficiary Request for Payment on Provider Record - UB-92 
and Electronic Billing (Part A and Part B) 
1  50.1.3  A3-3302.5  B3-3008      Signature on the Request for Payment by Someone Other Than 
the Patient 
1  50.1.4  A3-3302.6        Request for Payment as a Claim for HI Entitlement 
1  50.1.5  A3-3302.7        Refusal by Patient to Request Payment Under the Program 
1  50.1.6    B3-3057      When Beneficiary Statement is Not Required for 
Physician/Supplier Claim  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  50.1.7  A3-3305.1,   B3-3004,       Definition of a Claim for Payment 
A3-3312.2,   B3-3000 partial 
1  50.1.8  A3-3305.2,         Establishing Date of Filing - Postmark Date Carriers 
A3-3305.3 
1  50.2  A3-3603        Frequency of Billing for Providers 
1  50.2.1          Inpatient Billing from Hospitals and SNFs 
1  50.2.2          Frequency of Billing for Outpatient and Services to 
Intermediaries 
1  50.2.3  A3-3603.1        Submitting Bills In Sequence Ffor a Continuous Inpatient Stay or 
Outpatient Course of Treatment 
1  A3-3603.2,        Reprocess Inpatient or Hospice Claims in Sequence 
Definition of 
spell of 
illness from 
MIM-3035 
1  60          No Pay Bills 
1  70  A3-3600.2        Time Limitations for Filing Provider Claims 
1  70.1  A3-3600.2A        Determining Start Date of Timely Filing Period--Service Date 
1  70.2  A3-3600.2B        Definition of Claim 
1  70.2.1  A3-3600.2B1        Appropriate Medicare Contractor 
1  70.2.2  A3-3600.2B2        Form Prescribed by CMS  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  70.2.3  A3-3600.2B3        In Accordance with CMS Instructions 
1  70.2.3.1  A3-       Incomplete or Invalid Submissions 
3600.2B3a 
1  70.2.3.2  A3-       Handling Incomplete or Invalid Submissions 
3600.2B3b 
1    A3-        
3600.2B3c 
1  70.3  A3-3600.2C        Determining End Date of Timely Filing PeriodReceipt Date 
1             
1  70.4  A3-3600.2D        Determination of Timely Filing and Resulting Actions 
1  70.4.1          Part A Institutional Provider Services and Part A and Part B 
Home Health Services 
1  70.5  A3-3600.2E        Application to Special Claim Types 
1  70.6  A3-3600.2F        Filing Claim Where Usual Time Limit Has Expired 
1  70.7  A3-3600.2G        Exceptions Allowing Extension of Time Limit 
1  70.7.1  A3-3600.2G1        Administrative Error 
1  70.7.2  A3-3600.2G2        Statement of Intent 
1  70.7.3  A3-3600.2G3        Reopening of Determinations  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  80  A3-3600,   B3-13306,    HO-401,   Carrier and Intermediary Claims Processing Timeliness 
A3-3600.1  B2-5240.11  HO-401A,  
HH-462 
1  80.1          Control and Counting Claims 
1  80.2  A3-3600.1  B2-5240.11A    HO-401D  Definition of Clean Claim 
1  80.2.1  A3-3600.1-        Receipt Date 
Item 7 
1  80.2.1.1  A3- B2-5240.11D      Payment Ceiling Standards 
3600.1A.1 
1  80.2.1.2  A3-3600.1      HO-401B  Payment Floor Standards 
1  80.2.2  A3-3600.1-      HO-401C  Interest Payment on Clean Non-PIP Claims Not Paid Timely 
Item 5 
1  80.2.2.1    B2-5240.11C      Determining and Paying Interest 
1  80.2.2.2          Preparation of IRS Form 1099-INT 
1  80.3  A3-3600.1-  B2-5240.11B    HO-401E  Other Claims (Other Than Clean) 
Item 4 
1  80.3.1  A3-3605.1  B3-3005.1      Incomplete or Invalid Claims Processing Terminology 
1  80.3.2  A3-3605.2  B3-3005.2B      Handling Incomplete or Invalid Claims 
1  80.3.2.1  A3 3605.3  B3-3005.3,      Data Element Requirements Matrix  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  80.3.2.1.1    B3-3005.4,      Carrier Data Element Requirements 
R1813B3 
1  80.3.2.1.2    B3-3005.4,      Conditional Data Element Requirements for Carriers and 
R1813B3  DMERCs 
1  80.3.2.1.3          Carrier Specific Requirements for Certain Specialties/Services 
1  80.3.2.2  A3-3606        Intermediary Consistency Edits 
1  80.4  A3-3676        Enforcement of Provider Billing Timelines and Accuracy 
Standard to Continue PIP (Periodic Interim Payment) 
1  80.5          Do Not Forward Initiative (DNF) 
1  80.5.1    B3-4021,   B-02-023    Carrier DNF Requirements 
1  80.5.1.1      B-02-11    Reporting Requirements - Carriers 
1  80.5.2      A-02-12    Intermediary DNF Requirements 
1  80.5.2.1          Reporting Requirements - Intermediaries 
1  90        HO-408,   Patient Is a Member of an M+CO for Only a Portion of the 
HH-412  Billing Period 
1  100        HO-301,   Medicare as a Secondary Payer 
HO-469,  
42 CFR 411.32 
1  110        HO-413,   Provider Retention of Health Insurance Records 
HH-480,  
SNF 545  Chap  Sect  Int.  Carrier  PMs  Other  Description 
Pub. 13  Pub. 14 
1  110.1        HO-413,   Categories of Health Insurance Records to Be Retained 
HH-480,  
SNF 545.1 
1  110.2        SNF 545.3,   Microfilming Records 
HO-413,  
HH-480 
1  110.3          Retention Period 
1  110.4        HO-413.1,   Destruction of Records 
HH-480.1,  
SNF 545.4 
1  130  A3-3670    AB-00-38    Detection of Duplicate Claims 
1      B3-3999      Exhibit 1 - Data Element Requirements Matrix (Carrier)