(Medicare Claims Processing Manual)

10.1.9.5 - An A/B MAC (B) or DME MAC Receives a Claim for a UMWA Beneficiary  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a local contractor (Part B MAC or carrier/DME MAC) receives a Form CMS -1500 or electronic claim that is identified as a UMWA claim for Medicare payment that should be processed by the UMWA, the claim shall be returned as unprocessable.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 109  RARC: N127  MSN: N/A  10.1.9.6 - Medicare Carrier or RRB -Named Carrier to Welfare Carrier  (Rev. 2474, Issued: 05- 18-12, Effective: 07 -20-12, Implementation; -7-20-12)  When a Medicare carrier or RRB -named carrier receives a query reply from CMS that includes a disposition code 46 and a welfare administration carrier number, it transfers the claim to the welfare carrier and notifies the beneficiary. Any pertinent informat ion received or developed is transferred with the claim.   This occurs only if there is a State welfare carrier and the individual is identified in the beneficiary master record as a State buy -in enrollee for that State.  For more information on the definition of a welfare carrier, refer to Pub. 100- 04, Chapter 1, section 10.1.7.  10.1.9.7 - Protests Concerning Transfer of Requests for Payment to Carrier  (Rev. 2474, Issued: 05- 18-12, Effective: 07 -20-12, Implementation; -7-20-12)  If Palmetto GBA receives a protest concerning the transfer of a request for Medicare payment to the carrier, the protest, including pertinent name and claim number(s) information, is forwarded to:   Railroad Retirement Board  Medicare Section  844 Rush Street  Chicago, IL 60611   10.1.9.8 - Transfer of Claims Material Between Carrier and Intermediary (FI)  (Rev. 2474, Issued: 05- 18-12, Effective: 07 -20-12, Implementation; -7-20-12)  If a beneficiary erroneously submits a Form CMS -1490 (beneficiary -filed claim form) to a carrier with an itemized bill for services that must be paid by the FI, the carrier forwards such claims to the FI for the necessary action. The FI will inform the provider to submit a claim once the information is received from the carrier.   If the claim covers a combination of services both within and outside the carriers jurisdiction the carrier should retain the Form CMS -1490 and any claims material needed for processing and forward a photocopy of the Form CMS -1490 and other claims materia ls to the other involved carrier(s) or FI(s). The carrier should notify the beneficiary when it transfers the claim.   The patients signature on the Form CMS -1490 satisfied the signature requirement and protects the filing date for the provider billings. (See 70.1 for time limitations for filing claims).   10.1.9.9 - A DME MAC receives a Paper Claim with Items or Services that are in Another DME MAC's Payment Jurisdiction  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  When a DME MAC receives a claim submitted on the Form CMS -1500 for Medicare payment that should be processed by a DME MAC but was sent to the wrong DME MAC, the claim shall be returned as unprocessable.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 109  RARC: N104  MSN: N/A   DME MACs shall continue to follow existing procedures for misdirected beneficiary-submitted claims and electronic claims.   10.2 - FI Jurisdiction of Requests for Payment  (Rev. 1, 10- 01-03)  The FIs have jurisdiction for the following:    All Part A services (hospital, SNF, HHA, and hospice);    Most Part B services from providers that furnish Part A services; and    Part B facility services from CORFs, Renal; Dialysis Facilities, Rural Health Clinics, Religious Nonmedical Institutions, Outpatient Physical Therapy Centers, Federally Qualified Health Centers, and Community Mental Health Centers.  For example, rural health clinics may bill physician services to carriers under applicable physician provider numbers on carrier -compliant claim formats. Also, some DMEPOS may be billed by home health agencies on claims sent to RHHIs, and some physician, lab and ambulance services may be billed by some types  of providers submitting claims to FIs.   Within this general framework, specific jurisdiction among FIs is determined by which FI has received the official tie- in notice from the CMS RO. See 20 for procedures for provider nomination of its FI. Once an FI is assigned, that FI has jurisdiction for all services furnished by the provider or supplier, except those service outside the provider/suppliers scope of service. See the Medicare Claims Proces sing Manual chapters relating to the service for a description of who may bill the individual service, e.g. lab (Chapter 17) or DME (Chapter 20).   The RHHIs have jurisdiction for HHA and Hospice claims.  There is a national single FI for FQHCs.  United Government Systems processes all claims from independent FQHCs.   Regional RHC FIs have jurisdiction for claims from freestanding RHCs. See http://www.cms.hhs.gov/contacts/incardir.asp for a listing of RHC regional FIs. The host providers area FI has jurisdiction for provider based RHCs and FQHCs.   In addition some provider chains may elect a single FI for all providers in the chain.   A complete list of FIs and carriers and their service areas may be viewed at: http://www.cms.hhs.gov/contacts/incardir.asp.   Note that some providers and supplier under FI claims jurisdiction may also provide covered services outside the scope of the facility service, and may bill these services to the carrier.   Claims sent to the incorrect FI are returned to the provider with an instruction to bill the correct FI.   10.2.1 - FI Payment for Emergency and Foreign Hospital Services (Rev. 1, 10- 01-03)  A.  Beneficiary Services Outside United States -  Emergency Hospital Admissions   See chapter 3, for detailed information concerning beneficiary services outside the United States.  Generally, payment is made for emergency inpatient hospital services in qualified Canadian or Mexican hospitals in the following circumstances:    A Medicare beneficiary is in the United States when an emergency occurs, and a Canadian or Mexican hospital is closer to, or more accessible from, the site of the emergency than the nearest adequately equipped United States hospital that can provide emerge ncy services, or    The emergency occurred in Canada while the beneficiary is traveling between Alaska and another State without unreasonable delay and by the most direct route, and a Canadian hospital is closer to, or more accessible from, the site of the emergency than the nearest United States hospital.  For this purpose, an emergency occurring within the Canadian inland waterway between the States of Washington and Alaska is considered to have occurred in Canada.   The term United States means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, Northern Mariana Islands, American Samoa and, for purposes of services furnished on a ship, the territorial waters adjoining the land areas of the U.S.  A hospital that is not physically situated in one of the above jurisdictions is considered to be outside the United States, even if it is owned or operated by the United States Government.   B.  Nonemergency Inpatient Services Furnished in Foreign Hospitals   If the beneficiary resides in the United States, and a Canadian or Mexican hospital is closer to, or more accessible from, the beneficiarys home than the nearest adequately equipped United States hospital, Medicare will pay for covered services regardless  of whether an emergency exists.   Residence means the place in the U.S. where a person has a fixed and permanent home to which he intends to return whenever he is away.  At the time such services are furnished, the Canadian or Mexican hospital must be acc redited by the JCAH or by a hospital approval program of the country in which it is located having standards essentially equivalent to those of the JCAHO.   10.3 - Payments Under Part B for Services Furnished by Suppliers of Services to Patients of a Provider  (Rev. 1, 10- 01-03) B3-3115  Section 1861(w)(1)  of the Act permits a hospital, critical access hospital, skilled nursing facility, home health agency, or hospice to obtain under arrangement, services for which an individual is entitled to under Medicare. Doing so discharges the liability of such indivi dual or any other person to pay for the services.  This is required in specified situations where the provider is paid under a PPS system.  Examples of this include:    While a patient is under a home health plan of care, the HHA must provide all covered and medically reasonable home health services and certain supplies (subject to consolidated billing) either directly or under arrangement.   Where a patient is a SNF inpatient, the SNF must furnish all services within the scope of the SNH benefit.    Where a patient is a hospital inpatient, the hospital must furnish certain inpatient services.    Certain services are considered included in the rural health clinic or federally funded health clinic visit.  In such cases, the supplier must look to the provider for payment and the provider will bill the FI.   In some cases, the hospital, SNF, or HHA may also choose not to arrange for additional services in this and bill for them. In some cases the provider may instead arrange for the supplier to furnish the test and to bill the carrier.  The provider may make different arrangements with different suppliers.  For example a provider may arrange with a lab supplier for the lab to bill for all outpatient lab services and make arrangements with an x-ray supplier for the provider to bill for all x ray services to inpa tients and outpatients.   Similarly the supplier may make different arrangements for services to beneficiaries for whom only Part B benefits are payable, from arrangements for beneficiaries for whom Part A benefits are payable under a PPS system.   The FIs notify carriers of contracts that the hospital, critical access hospital, skilled nursing facility, home health agency, or hospice have reported with their suppliers. The carrier should confirm the suppliers understanding of the arrangements to as sure that the supplier does not bill inappropriately.   A description of basic services for each benefit type is in the Medicare Benefit Policy Manual and also in the Medicare Claims Processing Manual chapter specific to the provider.   10.4  Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal Authority  (Rev. 3537, Issued: 06- 08-16, Effective: 08 -08-16, Implementation: 08- 08-16)  Under Section 1862(a)(2) of the Social Security Act (the Act), the Medicare program does not pay for services if the beneficiary has no legal obligation to pay for the services and no other person or organization has a legal obligation to provide or pay for that service.  Also, under Section 1862(a)(3) of the Act, if services are paid for directly or indirectly by a governmental entity, Medicare does not pay for the services.  These provisions are implemented by regulations 42 C.F.R. 411.4, 411.6, and 411.8, respectively.   The regulation at 42 CFR 411.4(b) states:   Individuals who are in custody include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, on medical furlough, required to reside in mental health facilities, required t o reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule.   Moreover, 72 FR 47405 states further that the   definition of custody is in accordance with how custody is defined by Federal courts for purposes of the habeas corpus protections of the Constitution.  For example, the term custody is not limited solely to physical confinement. (Sanders v. Freeman, 221F.3d 846, 850- 851 (6PthP Cir. 2000).) Individuals on parole, probation, bail, or supervised release may be in custody.   42 CFR 411.4(b) goes on to describe the special conditions that must be met in order for Medicare to make payment for individuals who are in custody, 42 CFR 411.4(b) states: