16614 Federal Register / Vol. 78, No. 52 / Monday, March 18, 2013 / Rules and Regulations 

April 23, 1997). This action does not 

contain any information collections 

subject to OMB approval under the 

Paperwork Reduction Act (PRA), 44 

U.S.C. 3501 et seq., nor does it require 

any special considerations under 

Executive Order 12898, entitled Federal 

Actions to Address Environmental 

Justice in Minority Populations and 

Low-Income Populations (59 FR 7629, 

February 16, 1994). This action does not 

involve technical standards; thus, the 

requirements of Section 12(d) of the 

National Technology Transfer and 

Advancement Act of 1995 (15 U.S.C. 

272) do not apply. The Congressional 

Review Act, 5 U.S.C. 801 et seq., 

generally provides that before certain 

actions may take effect, the agency 

promulgating the action must submit a 

report, which includes a copy of the 

action, to each House of the Congress 

and to the Comptroller General of the 

United States. Because this action does 

not contain legally binding 

requirements, it is not subject to the 

Congressional Review Act. 

List of Subjects in 40 CFR Part 300 

Environmental protection, Air 

pollution control, Chemicals, Hazardous 

substances, Hazardous waste, 

Intergovernmental relations, Penalties, 

Reporting and recordkeeping 

requirements, Superfund, Water 

pollution control, Water supply. 

Dated: March 11, 2013. 

Mathy Stanislaus, 

Assistant Administrator, Office of Solid Waste 

and Emergency Response. 

For the reasons set out above, title 40, 

chapter I of the Code of Federal 

Regulations is amended as follows: 

PART 300—NATIONAL OIL AND 

HAZARDOUS SUBSTANCES 

POLLUTION CONTINGENCY PLAN 

■ 1. The authority citation for part 300 

continues to read as follows: 

Authority: 33 U.S.C. 1321(c)(2); 42 U.S.C. 

9601–9657; E.O. 12777, 56 FR 54757, 3 CFR, 

1991 Comp., p.351; E.O. 12580, 52 FR 2923, 

3 CFR, 1987 Comp., p.193. 

■ 2. Section 300.805 is amended by 

revising paragraph (c) to read as follows: 

§ 300.805 Location of the administrative 

record file. 

* * * * * 

(c) The lead agency may make the 

administrative record file available to 

the public in microform, computer 

telecommunications, or other electronic 

means. 

[FR Doc. 2013–06189 Filed 3–15–13; 8:45 am] 

BILLING CODE 6560–50–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Parts 405, 411, 412, 419, 424, 

and 489 

[CMS–1455–NR] 

Medicare Program; Medicare Hospital 

Insurance (Part A) and Medicare 

Supplementary Medical Insurance 

(Part B) 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Notice of CMS ruling. 

SUMMARY: This notice announces a CMS 

Ruling that establishes a policy that 

revises the current policy on Part B 

billing following the denial of a Part A 

inpatient hospital claim by a Medicare 

review contractor on the basis that the 

inpatient admission was determined not 

reasonable and necessary. This revised 

policy is intended as an interim 

measure until CMS can finalize a policy 

to address the issues raised by the 

Administrative Law Judge and Medicare 

Appeals Council decisions going 

forward. To that end, elsewhere in this 

issue of the Federal Register, we 

published a proposed rule entitled, 

‘‘Medicare Program; Part B Inpatient 

Billing in Hospitals,’’ to propose a 

permanent policy that would apply on 

a prospective basis. 

DATES: The CMS ruling announced in 

this notice is effective on March 13, 

2013. 

FOR FURTHER INFORMATION CONTACT: Ann 

Marshall, (410) 786–3059, for issues 

related to payment of Part B inpatient 

and Part B outpatient services. 

David Danek, (617) 565–2682, for 

issues related to general appeals policy. 

If you have a question about a 

pending appeal, please contact the 

entity (that is, Medicare contractor, 

Qualified Independent Contractor (QIC), 

Administrative Law Judge (ALJ) or the 

Appeals Council) where your appeal is 

pending. For those cases that were 

remanded from an ALJ to a QIC, HHS’ 

Office of Medicare Hearings and 

Appeals (OMHA) will post further 

information on its public Web site at 

www.hhs.gov/omha. The contact names 

listed will not have any information 

about specific, pending appeals. 

SUPPLEMENTARY INFORMATION: The CMS 

Administrator signed Ruling CMS– 

1455–R on March 13, 2013. This CMS 

Ruling, as well as other CMS Rulings are 

available at http://www.cms.gov/ 

Regulations-and-Guidance/Guidance/ 

Rulings/index.html. For the readers’ 

convenience, the text of the CMS Ruling 

1455–R is set forth in the Appendix to 

this notice of CMS ruling: 

(Catalog of Federal Domestic Assistance 

Program No. 93.773, Medicare—Hospital 

Insurance; and Program No. 93.774, 

Medicare—Supplementary Medical 

Insurance Program) 

Dated: March 13, 2013. 

Marilyn Tavenner, 

Acting Administrator, Centers for Medicare 

& Medicaid Services. 

Note: The following appendix will not 

appear in the Code of Federal Regulations. 

Appendix 

CMS Rulings 

Department of Health and Human Services 

Centers for Medicare & Medicaid Services 

Ruling No.: CMS–1455–R. 

Date: March 13, 2013. 

Centers for Medicare & Medicaid Services 

(CMS) Rulings are decisions of the 

Administrator of CMS that serve as 

precedential final opinions, orders and 

statements of policy and interpretation. They 

provide clarification and interpretation of 

complex provisions of the law or regulations 

relating to Medicare, Medicaid, Utilization 

and Quality Control Peer Review, private 

health insurance, and related matters. They 

are published under the authority of the 

Administrator. 

CMS Rulings are binding on all CMS 

components, Part A and Part B Medicare 

Administrative Contractors (MACs), 

Qualified Independent Contractors (QICs), 

the Provider Reimbursement Review Board, 

the Medicare Geographic Classification 

Review Board, and on the Medicare Appeals 

Council and Administrative Law Judges 

(ALJs) who hear Medicare appeals. Rulings 

promote consistency in interpretation of 

policy and adjudication of disputes. 

In light of numerous recent Medicare 

Appeals Council and ALJ decisions on a 

recurrent Medicare payment issue and in 

association with this Ruling, CMS is 

concurrently issuing a proposed rule, entitled 

‘‘Medicare Program; Part B Billing in 

Hospitals’’ addressing the policy of billing 

under Medicare Part B following a denial of 

a Medicare Part A hospital inpatient claim by 

a Medicare review contractor for the reason 

that an inpatient admission was not 

reasonable and necessary under section 

1862(a)(1)(A) of the Social Security Act (the 

Act). This Ruling is effective as of the 

issuance date, and addresses the treatment of 

such claims and associated appeals until the 

effective date of the final regulations for the 

proposed rule entitled, ‘‘Medicare Program; 

Part B Billing in Hospitals’’. 

Medicare Program 

Medicare Hospital Insurance (Part A) and 

Medicare Supplementary Medical Insurance 

(Part B). 


pmangrum on DSK3VPTVN1PROD with RULES
Federal Register / Vol. 78, No. 52 / Monday, March 18, 2013 / Rules and Regulations 16615 

Clarification of Billing Under Medicare Parts 

A and B 

Citations: Sections 1814, 1833, 1835, 1842, 

1862, 1866, 1870, 1879 and 1886 of the 

Social Security Act; 42 CFR Part 405 Subpart 

I, 411.402, Part 412, 419.21, 424.44, and 

489.21. 

Background 

When a Medicare beneficiary arrives at a 

hospital in need of medical or surgical care, 

the physician or other qualified practitioner 

may admit the beneficiary for inpatient care 

or treat him or her as an outpatient. In some 

cases, when the physician or other qualified 

practitioner admits the beneficiary and the 

hospital provides inpatient care, a Medicare 

claims review contractor, such as a Medicare 

Administrative Contractor (MAC), a Recovery 

Audit Contractor (RAC), or the 

Comprehensive Error Rate Testing (CERT) 

Contractor, subsequently determines that the 

inpatient admission was not reasonable and 

necessary under section 1862(a)(1)(A) of the 

Act, and therefore denies the associated Part 

A claim for payment. Under such 

circumstances, Medicare payment policy has 

permitted hospitals to bill a subsequent ‘‘Part 

B Inpatient’’ claim for only a limited set of 

medical and other health services referred to 

as ‘‘Part B Inpatient’’ or ‘‘Part B Only’’ 

services. (For more information, see, Internet 

Only Manual (IOM) Pub. 100–02, Medicare 

Benefit Policy Manual (MBPM), Chapter 6, 

Section 10; Prospective Payment System for 

Hospital Outpatient Services, Proposed Rule, 

63 FR 47560 (September 8, 1998) and Final 

Rule, 65 FR 18444 (April 7, 2000); Changes 

to the Hospital Outpatient Prospective 

Payment System for Calendar Year 2002, 

Proposed Rule, 66 FR 44698 through 44699 

(August 24, 2001) and Final Rule, 66 FR 

59891 through 59893, and 59915 (November 

30, 2001).) 

In an increasing number of cases, hospitals 

that have appealed these Part A inpatient 

claim denials to the ALJs and the Medicare 

Appeals Council have received decisions 

upholding the Medicare review contractor’s 

determination that the inpatient admission 

was not reasonable and necessary, but 

ordering payment of the services as if they 

were rendered at an outpatient or 

‘‘observation level’’ of care. These decisions 

effectively require Medicare to issue payment 

for all Part B services that would have been 

payable had the beneficiary been treated as 

an outpatient (rather than an inpatient), 

instead of limiting payment to only the set 

of Part B inpatient services that are 

designated in the MBPM. Moreover, the 

decisions have required payment regardless 

of whether the subsequent hospital claim for 

payment under Part B is submitted within 

the otherwise applicable time limit for filing 

Part B claims. 

The ALJ and Medicare Appeals Council 

decisions providing for payment of all 

reasonable and necessary Part B services 

under the circumstances previously 

described are contrary to CMS’ longstanding 

policies that permit billing for only a limited 

list of Part B inpatient services and require 

that the services be billed within the usual 

timely filing restrictions (MBPM, Chapter 6, 

Section 10); Prospective Payment System for 

Hospital Outpatient Services, Proposed Rule 

63 FR 47560 (September 8, 1998) and Final 

Rule, 65 FR 18444 (April 7, 2000); Changes 

to the Hospital Outpatient Prospective 

Payment System for Calendar Year 2002, 

Proposed Rule, 66 FR 44698 through 44699 

(August 24, 2001) and Final Rule, 66 FR 

59891 through 59893, and 59915, (November 

30 2001); Payment Policies Under the 

Physician Fee Schedule and Other Revisions 

to Part B for CY 2011; Final Rule (75 FR 

73449 and 73627, November 29, 2010). While 

decisions issued by the ALJs and the 

Medicare Appeals Council do not establish 

Medicare payment policy, we are bound to 

effectuate each individual decision. The 

increasing number of these types of decisions 

has created numerous operational 

difficulties. This Ruling establishes a 

standard process for effectuating these 

decisions and handling pending claims and 

appeals in the interim while CMS considers 

how to best address this issue going forward. 

The Ruling also addresses the scope of 

administrative review in these and other, 

similar cases. Until the final regulations 

entitled, ‘‘Medicare Program; Part B Inpatient 

Billing in Hospitals’’ are promulgated, CMS, 

through this Ruling, acquiesces to the 

approach taken in the aforementioned ALJ 

and Appeals Council decisions on the issue 

of subsequent Part B billing following the 

denial of a Part A hospital inpatient claim on 

the basis that the admission was not 

reasonable and necessary. The policy 

announced in this Ruling supersedes any 

other statements of policy on this issue and 

remains in effect until the effective date of 

the regulations that finalize the proposed rule 

entitled, ‘‘Medicare Program; Part B Inpatient 

Billing in Hospitals’’, which we are issuing 

concurrently with this Ruling. 

Ruling 

Part B Hospital Inpatient Billing 

In light of the numerous recent ALJ and 

Medicare Appeals Council decisions 

previously described, this Ruling establishes 

a policy that revises the current policy on 

Part B billing following the denial of a Part 

A inpatient hospital claim by a Medicare 

review contractor on the basis that the 

inpatient admission was determined not 

reasonable and necessary. This revised policy 

is intended as an interim measure until CMS 

can finalize a policy to address the issues 

raised by the ALJ and Medicare Appeals 

Council decisions going forward. To that end, 

we issued a proposed rule entitled, 

‘‘Medicare Program; Part B Inpatient Billing 

in Hospitals,’’ today, to propose a permanent 

policy on a prospective basis once the 

proposed rule is finalized. Accordingly, this 

Ruling is effective only until such time as the 

aforementioned proposed rule is finalized. 

To date, under MBPM, Chapter 6, Section 

10, a limited set of Part B inpatient services 

may be paid in the following circumstances: 

• No Part A prospective payment is made 

at all for the hospital stay because of patient 

exhaustion of benefit days before admission. 

• The admission was disapproved as not 

reasonable and necessary (and waiver of 

liability payment was not made). 

• The day or days of the otherwise covered 

stay during which the services were provided 

were not reasonable and necessary (and no 

payment was made under waiver of liability). 

• The patient was not otherwise eligible 

for or entitled to coverage under Part A. 

This Ruling applies only in the second 

circumstance listed previously, that is, when 

the admission was disapproved as not 

reasonable and necessary by a Medicare 

review contractor, and payment for the 

denied services was not made pursuant to 

section 1879 of the Act (and provided the 

hospital’s responsibility for repayment of an 

overpayment was not waived under section 

1870 of the Act). Because the other 

circumstances for Part B inpatient billing 

listed in the MBPM are not the subject of the 

administrative appeals that this Ruling is 

designed to address (for example, when a 

beneficiary has no coverage under Part A 

because he or she exhausts Part A benefits), 

the existing policy applies in all other 

applicable circumstances, and a hospital may 

continue to bill for only the limited set of 

Part B inpatient services and must do so 

within the timely filing requirements. 

Pursuant to this Ruling, when a Part A 

inpatient claim for a hospital inpatient 

admission is denied by a Medicare review 

contractor because the inpatient admission 

was not reasonable and necessary, the 

hospital may submit a Part B inpatient claim 

for more services than just those listed in the 

MBPM, Chapter 6, Section 10, to the extent 

additional reasonable and necessary services 

were furnished. In this case, the hospital may 

submit a Part B inpatient claim for payment 

for the Part B services that would have been 

payable to the hospital had the beneficiary 

originally been treated as an outpatient rather 

than admitted as an inpatient, except when 

those services specifically require an 

outpatient status, for example, outpatient 

visits, emergency department visits, and 

observation services. Such services that 

require an outpatient status cannot be billed 

for the time period the beneficiary spent in 

the hospital as an inpatient and cannot be 

included on the Part B inpatient claim (see 

the following discussion of patient status). 

Three-Day Payment Window Prior to the 

Inpatient Admission 

Current Medicare policy requires payment 

for certain outpatient services furnished on 

the date of an inpatient admission or during 

the 3-calendar days (or 1-calendar day for 

hospitals not paid under the hospital 

inpatient prospective payment systems 

(IPPS)) prior to the date of the inpatient 

admission (collectively, ‘‘the 3-day (or 1-day 

for non-IPPS hospitals) payment window 

prior to the inpatient admission’’) to be 

bundled with the payment for the inpatient 

stay. See IOM Pub. 100–04, Medicare Claims 

Processing Manual (MCPM), Chapter 3, 

Section 40.3 and Chapter 4, Section 10.12. 

Under this Ruling, in cases for which no 

Part A payment is made because the Part A 

inpatient claim is denied on the basis that the 

inpatient admission was not reasonable and 

necessary, hospitals may bill separately for 

the outpatient services furnished during the 

3-day (or 1-day for non-IPPS hospitals) 

payment window prior to the inpatient 

admission as the outpatient services that they 

were, including observation and other 


pmangrum on DSK3VPTVN1PROD with RULES
16616 Federal Register / Vol. 78, No. 52 / Monday, March 18, 2013 / Rules and Regulations 

services that were furnished in accordance 

with Medicare’s requirements. Because 

services provided during the 3-day (or 1-day 

for non-IPPS hospitals) payment window 

prior to the denied inpatient admission are 

outpatient services, these services may not be 

included on the Part B inpatient claim. 

Instead, hospitals may bill for these services 

on a Part B outpatient claim, which, in 

accordance with the policy announced in 

this Ruling, will not be subject to the usual 

timely filing restrictions discussed later in 

this Ruling. Hospitals may only submit 

claims for Part B inpatient and Part B 

outpatient services that are reasonable and 

necessary in accordance with Medicare 

coverage and payment rules. Hospitals must 

maintain documentation to support the 

services billed on a Part B inpatient claim for 

services rendered during the inpatient stay, 

in addition to those billed on a Part B 

outpatient claim for services rendered in the 

3-day (or 1-day for non-IPPS hospitals) 

payment window prior to the inpatient 

admission. 

Applicability 

This Ruling is effective on the date of 

issuance. It applies to Part A hospital 

inpatient claims that were denied by a 

Medicare review contractor because the 

inpatient admission was determined not 

reasonable and necessary, as long as the 

denial was made: (1) While this Ruling is in 

effect; (2) prior to the effective date of this 

Ruling, but for which the timeframe to file an 

appeal has not expired; or (3) prior to the 

effective date of this Ruling, but for which an 

appeal is pending. This Ruling does not 

apply to Part A hospital inpatient claim 

denials for which the timeframe to appeal 

expired prior to the effective date of this 

Ruling, and it does not apply to inpatient 

admissions deemed by the hospital to be not 

reasonable and necessary (for example, 

through utilization review or other selfaudit). 

Treatment of Pending Appeals and Appeal 

Rights 

We are aware that there are currently 

thousands of appeals pending that are subject 

to this Ruling. In determining the least 

burdensome approach for both hospitals and 

CMS, we are publishing this Ruling to 

provide hospitals with notice of their right to 

withdraw pending appeals of Part A claim 

denials that are subject to this Ruling, and 

instead submit Part B claims for payment. 

Requests for withdrawal of pending Part A 

claim appeals must be sent to the adjudicator 

with whom the appeal is currently pending, 

except where the appeal has been remanded 

from an ALJ to a QIC. Under this Ruling, 

appeals of Part A claim denials that were 

remanded from the ALJ level to the QIC level 

will be returned to the ALJ level for 

adjudication of the Part A claim appeal 

consistent with the scope of review 

explained later in this Ruling. QICs will send 

affected hospitals notice regarding this 

action. The Office of Medicare Hearings and 

Appeals (OMHA) will provide instructions 

for submitting requests for withdrawal of ALJ 

hearings, including cases that were remanded 

from an ALJ to a QIC. OMHA will post the 

instructions on its public Web site at 

www.hhs.gov/omha, or appellants may call 

any OMHA Field Office (included in the 

Notice of Hearing sent by an ALJ and on the 

OMHA Web site) to request a copy of the 

instructions by mail or facsimile. Until and 

unless adjudicators receive a request for 

withdrawal, they will continue processing all 

pending Part A appeals that are subject to 

this Ruling. 

In order to prevent duplicate billing and 

payment, a hospital may not have 

simultaneous requests for payment under 

both Parts A and B for the same services 

provided to a single beneficiary on the same 

dates of service. Thus, if a hospital chooses 

to submit a Part B claim for payment 

following the denial of a Part A inpatient 

admission, the hospital cannot also maintain 

its request for payment for the same services 

on the Part A claim. In this situation, the 

hospital must either choose to no longer 

pursue an appeal of the Part A claim denial 

(and thus, as a practical matter, any 

determination or appeal decision becomes 

final or binding, allowing the hospital to 

submit its Part B claim) or must withdraw 

any pending appeal request on the Part A 

claim denial prior to the submission of the 

Part B claim. The request to withdraw the 

pending Part A claim appeal must be sent to 

the entity currently processing such appeal, 

and the entity will issue a dismissal notice. 

If a hospital submits a Part B claim for 

payment without withdrawing its appeal 

request, the Part B claim for payment may be 

denied as a duplicate. Once the hospital 

submits a Part B claim, parties will no longer 

be able to appeal the Part A claim. However, 

parties will be able to exercise their appeal 

rights for the subsequent Part B claim under 

existing procedures in 42 CFR part 405 

subpart I. 

If the hospital elects to withdraw its Part 

A appeal and submit a Part B claim, the 

hospital will have 180 days from the date of 

receipt of the appeal dismissal notice to 

submit the claim. If the appeal of the Part A 

claim remains pending, the hospital may 

submit a Part B claim if the Part A appeal is 

later withdrawn, or an unfavorable Part A 

appeal decision becomes final or binding, in 

which case, as explained later in this Ruling, 

the hospital will have 180 days from the date 

of receipt of the final or binding decision, or 

the date of receipt of the dismissal notice to 

submit the Part B claim. 

Time Period Within Which a Provider Must 

Bill 

Consistent with longstanding policy, the 

filing of Part B inpatient and Part B 

outpatient claims would be considered new 

claims subject to the time limits for filing 

claims described in sections 1814(a)(1), 

1835(a), and 1842(b)(3)(B) of the Act, and 42 

CFR 424.44. However, as an interim measure 

until the final rule entitled, ‘‘Medicare 

Program; Part B Inpatient Billing in 

Hospitals’’ can be issued, we are adopting 

(although not endorsing) the decisions of the 

ALJs and the Medicare Appeals Council that 

subsequent Part B rebilling by a hospital in 

situations covered by this Ruling is 

supported by concepts of adjustment billing. 

Under this approach, Part B inpatient and 

Part B outpatient claims that are filed later 

than 1-calendar year after the date of service 

are not to be rejected as untimely by 

Medicare’s claims processing system as long 

as the corresponding denied Part A inpatient 

claim was filed timely in accordance with 42 

CFR 424.44. 

If a hospital with a pending appeal for a 

Part A claim denial subject to this Ruling 

withdraws its appeal, it will have 180 days 

from the date of receipt of the dismissal 

notice to file its Part B claim(s). If a hospital 

with a pending appeal for a Part A claim 

denial subject to this Ruling does not 

withdraw its appeal, the hospital has 180 

days from the date of receipt of the final or 

binding unfavorable appeal decision (or 

subsequent dismissal notice) to submit its 

Part B claim(s). For example, if an appellant 

receives an unfavorable reconsideration 

decision but decides not to request a hearing 

before an ALJ, or the time to request a 

hearing expires, the reconsideration decision 

becomes binding, and the Part B claim(s) may 

be filed within 180 days of the date of receipt 

of the reconsideration decision. If a hospital 

receives a denial of a Part A inpatient claim 

subject to this Ruling for which there is no 

pending appeal, and the denial is not 

subsequently appealed, the hospital will 

have 180 days from the date of receipt of the 

initial or revised determination on the Part A 

inpatient claim (that is, the date of the 

remittance advice) to submit its Part B 

claim(s). The date of receipt of an initial or 

revised determination, or an appeal decision 

or dismissal notice is presumed to be 5 days 

after the date of such notice or decision, 

unless there is evidence to the contrary. 

Scope of Review for Part A Inpatient Claim 

Denials 

As noted earlier in this Ruling, a number 

of recent appeal decisions for Part A 

inpatient claim denials by a Medicare review 

contractor have affirmed the denial of the 

Part A inpatient admission, but ordered that 

payment be issued as if services were 

provided at an outpatient or ‘‘observation 

level’’ of care under Part B of the Medicare 

Program. These decisions ordered payment 

under Part B (or consideration of payment for 

services furnished that the contractor 

determined to be covered and payable under 

Part B), even though a Part B claim had not 

been submitted for payment. We note that 

these decisions are in conflict with existing 

policy. Thus, we are clarifying in this Ruling 

that hospitals are solely responsible both for 

submitting claims for items and services 

furnished to beneficiaries and determining 

whether submission of a Part A or Part B 

claim is appropriate. As specified in 42 CFR 

405.904(a)(2), once a hospital submits a 

claim, the Medicare contractor can make an 

initial determination and determine any 

payable amount. Under existing Medicare 

policy, if such a determination is appealed, 

an appeals adjudicator’s scope of review is 

limited to the claim(s) that are before them 

on appeal, and such adjudicators may not 

order payment for items or services that have 

not yet been billed or have not yet received 

an initial determination. (See 42 CFR 

405.920, 405.940, 405.948, 405.954, 405.960, 

405.968, 405.974, 405.1000, 405.1032, 


pmangrum on DSK3VPTVN1PROD with RULES
Federal Register / Vol. 78, No. 52 / Monday, March 18, 2013 / Rules and Regulations 16617 

405.1100, and 405.1128.) If a hospital 

submits an appeal of a determination that a 

Part A inpatient admission was not 

reasonable and necessary, the only issue 

before the adjudicator is the propriety of the 

Part A claim, not any issue regarding any 

potential Part B claim the provider has not 

yet submitted. 

Patient Status Under the Ruling 

For the Part B claims billed under this 

Ruling, the beneficiary’s patient status 

remains inpatient as of the time of inpatient 

admission and is not changed to outpatient, 

because the beneficiary was formally 

admitted as an inpatient and there is no 

provision to change a beneficiary’s status 

after she/he is discharged from the hospital. 

The beneficiary is considered an outpatient 

for services billed on the Part B outpatient 

claim, and is considered an inpatient for 

services billed on the Part B inpatient claim. 

Part A to Part B Rebilling Demonstration 

The Part A to Part B Rebilling 

Demonstration is being terminated. We will 

communicate to hospitals and contractors the 

details regarding termination of this 

Demonstration. 

Operational Considerations 

We will issue operational and any other 

applicable regulatory guidance that is 

necessary to implement this Ruling, 

including the mechanics of how hospitals 

should bill for Part B inpatient and Part B 

outpatient services under this Ruling. 

Instructions to Contractors 

All Medicare contractors including MACs 

and QICs must implement and follow this 

Ruling until such time as CMS addresses 

these issues further. 

Held: Pursuant to this Ruling, when a Part 

A claim for a hospital inpatient admission is 

denied by a Medicare review contractor 

because the inpatient admission was not 

reasonable and necessary, the hospital may 

submit a Part B inpatient claim for more 

services than just those listed in the MBPM, 

Chapter 6, Section 10, to the extent 

additional reasonable and necessary services 

were furnished. In this case, the hospital may 

submit a Part B inpatient claim for payment 

for the Part B services that would have been 

payable to the hospital had the beneficiary 

originally been treated as an outpatient rather 

than admitted as an inpatient, except when 

those services specifically require an 

outpatient status, for example, outpatient 

visits, emergency department visits, and 

observation services. Hospitals must submit 

their Part B claim within the timeframes 

specified in this Ruling. Further, where no 

Part A payment is made because the Part A 

inpatient claim is denied on the basis that the 

inpatient admission was not reasonable and 

necessary, hospitals may continue to bill 

separately for the outpatient services 

furnished during the 3-day (or 1-day for nonIPPS hospitals) payment window prior to the 

inpatient admission, including observation 

and other services that were furnished in 

accordance with Medicare’s requirements. In 

order to prevent duplicate billing and 

payment, a hospital may not have 

simultaneous requests for payment under 

both Parts A and B for the same services 

provided to a single beneficiary on the same 

dates of service. Thus, if a hospital chooses 

to submit a Part B claim for payment 

following the denial of a Part A inpatient 

admission, the hospital cannot also maintain 

its request for payment for the same services 

on the Part A claim. This Ruling applies to 

Part A hospital inpatient claims that were 

denied by a Medicare review contractor 

because the inpatient admission was 

determined not reasonable and necessary, as 

long as the denial was made: (1) While this 

Ruling is in effect; (2) prior to the effective 

date of this Ruling, but for which the 

timeframe to file an appeal has not expired; 

or (3) prior to the effective date of this 

Ruling, but for which an appeal is pending. 

This Ruling does not apply to Part A hospital 

inpatient claim denials for which the 

timeframe to appeal expired prior to the 

effective date of this Ruling, and it does not 

apply to inpatient admissions deemed by the 

hospital to be not reasonable and necessary 

(for example, through utilization review or 

other self-audit). For the Part B claims billed 

under this Ruling, the beneficiary’s patient 

status remains inpatient as of the time of 

inpatient admission and is not changed to 

outpatient, because the beneficiary was 

formally admitted as an inpatient and there 

is no provision to change a beneficiary’s 

status after she/he is discharged from the 

hospital. The beneficiary is considered an 

outpatient for services billed on the Part B 

outpatient claim, and is considered an 

inpatient for services billed on the Part B 

inpatient claim. 

Effective Date 

This Ruling is effective March 13, 2013. 

Dated: lllllllllllllllll

Marilyn Tavenner, 

Acting Administrator, Centers for Medicare & 

Medicaid Services. 

[FR Doc. 2013–06159 Filed 3–13–13; 4:15 pm] 

BILLING CODE P 

DEPARTMENT OF COMMERCE 

National Oceanic and Atmospheric 

Administration 

50 CFR Part 679 

[Docket No. 111207737–2141–02 and 

1112113751–2102–02] 

RIN 0648–XC569 

Fisheries of the Exclusive Economic 

Zone Off Alaska; Sablefish Managed 

Under the Individual Fishing Quota 

Program 

AGENCY: National Marine Fisheries 

Service (NMFS), National Oceanic and 

Atmospheric Administration (NOAA), 

Commerce. 

ACTION: Temporary rule; opening. 

SUMMARY: NMFS is opening directed 

fishing for sablefish with fixed gear 

managed under the Individual Fishing 

Quota (IFQ) Program and the 

Community Development Quota (CDQ) 

Program. The season will open 1200 

hours, Alaska local time (A.l.t.), March 

23, 2013, and will close 1200 hours, 

A.l.t., November 7, 2013. This period is 

the same as the 2013 commercial 

halibut fishery opening dates adopted 

by the International Pacific Halibut 

Commission. The IFQ and CDQ halibut 

season is specified by a separate 

publication in the Federal Register of 

annual management measures. 

DATES: Effective 1200 hours, A.l.t., 

March 23, 2013, until 1200 hours, A.l.t., 

November 7, 2013. 

FOR FURTHER INFORMATION CONTACT: 

Obren Davis, 907–586–7228. 

SUPPLEMENTARY INFORMATION: Beginning 

in 1995, fishing for Pacific halibut and 

sablefish with fixed gear in the IFQ 

regulatory areas defined in 50 CFR 679.2 

has been managed under the IFQ 

Program. The IFQ Program is a 

regulatory regime designed to promote 

the conservation and management of 

these fisheries and to further the 

objectives of the Magnuson-Stevens 

Fishery Conservation and Management 

Act and the Northern Pacific Halibut 

Act. Persons holding quota share receive 

an annual allocation of IFQ. Persons 

receiving an annual allocation of IFQ 

are authorized to harvest IFQ species 

within specified limitations. Further 

information on the implementation of 

the IFQ Program, and the rationale 

supporting it, are contained in the 

preamble to the final rule implementing 

the IFQ Program published in the 

Federal Register, November 9, 1993 (58 

FR 59375) and subsequent amendments. 

This announcement is consistent with 

§ 679.23(g)(1), which requires that the 

directed fishing season for sablefish 

managed under the IFQ Program be 

specified by the Administrator, Alaska 

Region, and announced by publication 

in the Federal Register. This method of 

season announcement was selected to 

facilitate coordination between the 

sablefish season, chosen by the 

Administrator, Alaska Region, and the 

halibut season, adopted by the 

International Pacific Halibut 

Commission (IPHC). The directed 

fishing season for sablefish with fixed 

gear managed under the IFQ Program 

will open 1200 hours, A.l.t., March 23, 

2013, and will close 1200 hours, A.l.t., 

November 7, 2013. This period runs 

concurrently with the IFQ season for 

Pacific halibut announced by the IPHC. 

The IFQ halibut season will be specified 

by a separate publication in the Federal 

Register of annual management 

measures pursuant to 50 CFR 300.62. 


pmangrum on DSK3VPTVN1PROD with RULES