(Medicare Claims Processing Manual)

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:   Payment may be made for services furnished to individuals or groups of individuals who are in the custody of the police or other penal authorities or in the custody of a government agency under a penal statute only if the following conditions are met: (1)  State or local law requires those individuals or groups of individuals to repay the cost of medical services they receive while in custody. (2) The State or local government entity enforces the requirement to pay by billing all such individuals, whether or not covered by Medicare or any other health insurance, and by pursuing the collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of other debts.   Exclusion from Coverage:   In accordance with the foregoing statutory and regulatory provisions, Medicare excludes from coverage items and services furnished to beneficiaries in State or local government custody under a penal statute, unless, it is determined that the State or local  government enforces a legal requirement that all prisoners/patients repay the cost of all healthcare items and services rendered while in such custody and also pursues collection efforts against such individuals in the same way, and with the same vigor, a s it pursues other debts.  CMS presumes that a State or local government that has custody of a Medicare beneficiary under a penal statute has a financial obligation to pay for the cost of healthcare items and services.  Therefore, Medicares policy is to d eny payment for items and services furnished to beneficiaries in State or local government custody.   Implementation   CMS has established claim level editing to implement this policy using data received from the Social Security Administration (SSA).  Specifically, the data contain the names of the Medicare beneficiaries and time periods when the beneficiary is in such Sta te or local custody.  These data will be compared to the data on the incoming claims.  CWF will reject claims where the dates from the SSA file and the dates of service on the claim overlap. Any claims rejected by CWF will contain a trailer to the Medicare contractor indicating the date span covered. Contractors will, in turn, deny payment of such claims.  However, providers and suppliers that render services or items to a prisoner or patient in a jurisdiction that meets the conditions of 42 CFR 411.4(b) should indicate this fact with the use of modifier QJ (for A/B MAC (B) or DME MAC processed claims or for  outpatient claims processed by A/B MAC (A).   Appeals:   A party to a claim denied in whole or in part under this policy may appeal the initial determination on the basis that, on the date of service, (1) the conditions of  411.4(b) were met, or (2) the beneficiary was not, in fact, in the custody of a State or  local government under authority of a penal statute.   A/B MAC (A)/RHHI Claims Processing Procedures   A/B MACs (A) must deny claims for items and services rendered to beneficiaries under State or local government custody when CWF rejects the claim.  Provide appeal rights as specified above.   Providers that render services or items to a prisoner or patient in a jurisdiction that meets the conditions of 42 CFR 411.4(b) should indicate this fact on the claim by billing as follows:   For outpatient claims, providers shall append a HCPCS modifier QJ on all lines with a line item date of service during the incarceration period.   For inpatient claims where the incarceration period spans only a portion of the stay, hospitals shall identify the incarceration period by billing as non- covered all days, services and charges that overlap the incarceration period.  Non- coverage billing guidelines can be found in Pub. 100- 04, Chapter 1, Section 60.   (NOTE:  When the inpatient claim is correctly billed, the processing contractor will append the payer -only condition code 63, which will allow the claim to process for payment.  This condition code indicates that the provider has been instructed by the state or local government agency that requested the healthcare items or services provided to the patient of the State or local government entity that it pursues collection of debts incurred for furnishing such items or services with the same vigor and in the same manner as any other debt.)   A/B MAC (B)/DME MAC Claims Processing Procedures   A/B MAC (B) and DME MACs must deny claims for items and services rendered to beneficiaries when rejected by CWF. Provide appeal rights as specified above.   Physicians and other suppliers that render services to a prisoner or patient in a jurisdiction that meets the conditions of 42 CFR 411.4(b) should indicate this fact on the claim.  Providers should use the QJ modifier. Language approved for QJ reads:   Services/items provided to a prisoner or patient in State or local custody, however, the State or local government, as applicable, meets the requirements in 42 CFR 411.4(b).   This modifier indicates that the physician or other supplier has been instructed by the state or local government agency that requested the healthcare items or services provided to the patient that State or local law makes the prisoner or patient responsib le to repay the cost of Medical services and that it pursues collection of debts incurred for furnishing such items or services with the same vigor and in the same manner as any other debt.      10.5 - Claims Processing Requirements for Deported Beneficiaries  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys 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.   Section 202(n) of the Social Security Act (the Act), requires the termination of Title II benefits upon deportation.  Moreover, Sections 226 and 226(A) of the Act provide that no payments may be made for benefits under Part A of Title XVIII of the Act if t here is no monthly benefit payable under Title II.  Section 1836 of the Act limits Part B benefits to those who are either entitled to Part A benefits or who are age 65 and a United States (U.S.) resident, U.S. citizen, or a lawfully admitted alien residin g permanently in the U.S.  Given that, a deported beneficiary is not allowed to enter the U.S. and cannot be lawfully present in the United States to receive Medicare- covered services, Medicare payment cannot be made for Part B Benefits.   An audit of Medicare payments by the Office of Inspector General identified a vulnerability for the Medicare trust fund with respect to this issue.  The study identified improper payments for beneficiaries, who, on the date of service on the claim, had bee n deported.  To address this vulnerability, CMS is establishing claim level editing using data from the Social Security Administration (SSA).  Specifically, the data contains the name and Medicare beneficiary identifier of the Medicare beneficiary and the month the deportation is effective.  CWF will reject claims where the effective date on the Master Beneficiary Record is equal to or greater than the date of service on the claim. All claims rejected by CWF shall be denied by the respective A/B MAC (B), DME MAC, A/B MAC (HHH) or A/B MAC (A) that submi tted the claim to CWF.   Policy:   Medicare payment shall not be made for an item or service furnished to an individual that has been deported from the United States.  Appeals:  A party to a claim denied in whole or in part under this policy may appeal the initial determination on the basis of the deportation status at the time the item or service was furnished.        10.5.1 - Implementation of Payment Policy for Deported Medicare Beneficiaries  (Rev. 4201, Issued: 01 -18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys 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.  CWF Editing of Claims   1. An auxiliary file shall be established in the Common Working File to contain deportation status.  2. This auxiliary file will be the basis for an edit that rejects claims submitted by Medicare contractors.   3. The edit will reject a claim where the Medicare beneficiary identifier on the claim matches the Medicare beneficiary identifier on the Master Beneficiary Record and the date of service is on or after the date of deportation.   B.  Contractors Actions   Medicare contractors shall deny claims for items and services when rejected by CWF.  The contractor shall refer to the CWF documentation on this subject for the error code assigned to this editing.  All denials will provide appeal rights as specified in section 10.5.  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: PR CARC: 96  RARC: N126  MSN: 16.56  20 - Provider Assignment to FIs and MACs  (Rev. 1707; Issued:  03-27- 09; Effective:  04 -027-09; Implementation:  04-27-09)   A. The Process of Moving Providers from FIs to MACs   1. The General Case   An existing Medicare provider with a claims history will remain in its current workload assignment.   As each MAC contract is awarded, the new MAC will take over workload from the carriers and FIs that serviced the state(s) in the given MAC jurisdiction.  The Part A and Part B workload segments for each of the states in the given MAC jurisdiction will be moved one-by-one in the 12 months following the final award.  The specific requirements associated with workload transfers will be directed through formal CMS transmittals.   A new provider (also known as an initial enrollment) will be assigned to the FI or MAC that covers the state where the provider is located, unless the assignment is directed to a non-geographic workload by 20B below.  A special exception exists for a Multi -Provider Complex/Sub-Unit relationship (ref: 42 CFR 483.5(b)).  An initial enrollment for a sub-unit will be assigned to the FI or MAC that currently serves the existing parent hospital  even if the parent hospital is not presently billing in accordance with the geographic assignment rule.  Each such case is fact-specific and will be treated on an individual basis.   2. Out of Jurisdiction Providers  An out-of-jurisdiction provider (OJP) is a provider that is not currently assigned to the A/B MAC or FI in accordance with B.1-5 below (including the geographic assignment rule.)  For example, an individual, freestanding provider located in Maine, but currently assigned to the Wisconsin FI, would be an OJP.  Many legacy Part A workload segments may include a number of OJPs.  Examples of how an OJP may have been assigned to the given Part A segment include:  a. Individual provider nominations.  (Note MMA 911 repealed the provider nomination provisions of the Act.);   b. Chains being granted single FI status; and  c. Legacy -world regional and national FIs for specific provider types such as FQHCs, RHCs, and ESRD facilities.   New MACs will initially service some OJPs until CMS undertakes the final reassignment of all OJPs to their destination MACs based on the geographic assignment rule and its exceptions.   CMS will start the overall transfer of OJPs to their final destination MACs after all 15 A/B MACs have been implemented.  Each move will be dependent on the then- current implementation status of the systems that support the cost report audit, claims proces sing, and provider enrollment functions at the departure and destination MACs.  Some providers will need to submit or update their Medicare enrollment record before being reassigned.   B. The Settled MAC Environment