(Medicare Claims Processing Manual)

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 C hapter 27 for handling various disposition codes, trailers, and error codes.   10.1.3 - Importance of Medicare beneficiary identifier s                               (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 insuranc e 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 cos ts.  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 hospita lization 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 r ecords 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 nonbene ficiary 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 assura nce 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 app lication 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 -beneficiar ies.  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 contai n 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 otherwis e 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 w ho 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;