(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 2 - Admission and Registration Requirements   Table of Contents  (Rev. 12423; Issued: 12- 20-23)  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.  Transmittals for Chapter 2  01 - Purpose of Chapter  05 - Definition of Provider and Supplier  10 - General Admission and Registration Rules  10.1 -  Medicare beneficiary identifiers  10.1.1 -  Changes to Medicare beneficiary identifier s 10.1.2 -  Contractor Procedures for Obtaining Missing or Incorrect Medicare beneficiary identifiers  10.1.3 -  Importance of Medicare beneficiary identifiers  10.2 -  Prohibition Against Waiver of Health Insurance Benefits as a Condition of Admission  10.3 -  Requiring Prepayment as a Condition of Admission is Prohibited 10.4 -  When Prepayment May Be Requested  10.5 -  Hospital and Skilled Nursing Facility (SNF) Verification of Prior Hospital Stay Information for Determining Deductible and Benefit Period Status  10.6 -  Hospitals May Require Prepayment for Noncovered Services  10.7 -  Compliance With Agreement  10.8 -  Request for Payment Should Be Obtained in All Cases as Protective Application for Hospital Insurance Benefits  10.9 -  A/B MAC (A) or (HHH)  Requests to Verify Patients  Medicare beneficiary identifier  10.10 -  A/B MAC (A) or (HHH)  Learns Beneficiary is an HMO Enrollee  10.11 -  Retroactive Entitlement 10.12 -  SNF Verification of Prior Hospital Stay and Transfer Requirements  20 - Obtaining Information to Determine Whether to Bill Medicare or Another Payer  20.1 -  Provider Development of Medicare Secondary Payer  30 - Provider/Supplier Obtaining/Verifying the Medicare beneficiary identifier and Entitlement Status  30.1 -  Cross -Reference of  Medicare beneficiary identifier  30.2 -  Health Insurance (HI) Card  30.3 -  Temporary Eligibility Notice  30.4 -  Certificate of Social Insurance Award  30.5 -  Medicare Summary Notice (MSN)  30.6 -  Provider Access to CMS and A/B MAC (A) or (HHH)  Eligibility Data  30.6.1 -  Reserved  30.6.1.1 -  Part A Inquiry (HIQA) Screen Display  30.6.1.2 -  Part A Inquiry Reply (HIQAR) Screen Display 30.6.1.3 -  Part A Inquiry (HUQA) Data  30.6.1.4 -  Part A Inquiry Reply (HUQAR) Data  30.6.1.5 -  Health Insurance Query for Home Health Agencies (HIQH)  30.6.2 -  Reserved  30.6.3 -  Reserved  30.6.4 -  Reserved  30.6.5 -  Reserved  30.6.6 -  Reserved  30.8 -  Reserved  30.10 -  Reserved  30.11 -  Reserved  30.12 -  Reserved  30.13 -  Reserved  30.14 -  Reserved  30.15 -  Reserved  30.16 -  Reserved  30.17 -  Reserved  30.18 -  Reserved  30.19 -  Reserved  30.19.1 -  Reserved  30.19.2 -  Reserved  30.19.3 -  Reserved  30.19.4 -  Reserved  30.20 -  Reserved  30.21 -  Requesting Assistance in Resolving Problem Areas in the Inquiry/Inquiry Response Procedures  30.21.1 -  HMO- Related Master File Corrections  30.22 -  Provider Problems Obtaining Entitlement Information 50 - Critical Case Procedures -  Establishing Entitlement Under Part A and B  60 - Reserved  60.1 -  Reserved  60.2 -  Reserved  70 - SSO Assistance in Resolving Entitlement Status Problems  90 - Outpatient Hospital Registration Procedures  90.1 -  Patient Identification  90.2 -  Determining Whom to Bill  90.3 -  Source of Admission -  Outpatient Hospital 90.4 -  Type of Bill  90.5 -  Definition of Diagnostic Services  90.6 -  Definition of Encounter  100 -  Reserved  100.1 -  Reserved  110 -  Reserved  110.1 -  Reserved  120 -  Reserved  01 - Purpose of Chapter  (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)  This chapter describes general requirements with respect to verifying an individuals Medicare eligibility and entitlement status for providers, suppliers, A/B MACs (A), (B), and (HHH), and DME MACs.  It also includes general requirements for hospitals for  determining the source admission for use later in the claims process.  05 - Definition of Provider and Supplier  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    This chapter uses the definition of provider and supplier found in 42 CFR 400.202.  These are:    Provider means a hospital, a CAH, a skilled nursing facility, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice that has in effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech -language pathology services, or a community mental health center that has in effect a similar agreement but only to furnish partial hospitaliz ation or intensive outpatient  services.    Supplier  means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.    Note that while rural health clinics, Federally qualified health centers, and renal dialysis facilities are suppliers under the regulation, they submit most claims to A/B MACs (A).   10 - General Admission and Registration Rules  (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)  The following is a general description of requirements and prohibited activities that apply to admission for inpatient services or registration for other healthcare services.  Upon admission, Prospective Payment System (PPS) hospitals and acute care hospitals in areas with waivers from PPS are required to give the notice, An Important Message from Medicare, to beneficiaries (available at www.cms.gov/Medicare/Medicare -General -Information/BNI/downloads/RevisedImportantMessageFromMedicare05_2007.pdf ).  The facility inserts its Quality Improvement Organizations (QIO) name, address, and phone number.  It provides this notice to each Medicare patient or the patients representative.  The CMS does not supply copies of the notice.   Upon admission of a Medicare beneficiary to an institution that bills Medicare, or as soon thereafter as practical, the provider must verify a patients eligibility in order to process the bill.  The provider may obtain this eligibility information directly from the patient or through the providers A/B MAC (A)s limited Medicare eligibility data.  See 30.6.  The provider contacts its A/B MAC (A) to obtain technical instructions regarding how this access may be implemented along with hardware/software compatibility details.   This information does not represent a definitive eligibility status.  If the individual is not on file, the provider uses the usual admission and billing procedure in effect, independent of this data access.   Disclosure of CMS eligibility data is restricted under the provisions of the Privacy Act of 1974.  This information is confidential, and may be used only for verifying a patients eligibility to benefits under the Medicare program.  Penalties for misuse by anyone may result in being found guilty of a misdemeanor and paying a fine not more than $5,000.  10.1 - Medicare beneficiary identifiers                                                        (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 CMS maintains the electronic records for individuals enrolled in the health insurance program.  The CMS issues health insurance cards where entitlement is established through the Social Security Administration (SSA), and the Railroad Retirement Board (RRB) issues health insurance cards where entitlement is established through RRB.   See Chapter 2 of the Medicare General Information, Eligibility, and Entitlement Manual (Pub. 100- 01) for an extended discussion of HI cards and Medicare beneficiary identifiers.                                                                    10.1.1 - Changes to 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.   Changes in an individuals entitlement to Medicare benefits may result in an individual being assigned a completely different HICN.  For example, an individual not entitled to monthly benefits (000- 00-0000T) marries and becomes entitled to wifes benefits on her husbands account (111- 11-1111B).  If a claim is submitted under the old HICN, the Common Working File (CWF) disposition code 51 will notify the A/B MAC (A), (B), (HHH), or DME MAC (whom we will refer to as the MAC when all are meant) of the new HIC N.  The MAC will annotate its records and use the new HICN when submitting future bills or claims.   10.1.2 - Contractor Procedures for Obtaining Missing or Incorrect 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.   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.