(Medicare Claims Processing Manual)

 Nonmedical nursing personnel, for Medicare payment purposes, perform services (e.g., serving meals, assisting with activities of daily living) that are strictly nonmedical/non- religious.  The statute and court order mandates only the coverage and payment under Part A for reasonable and necessary nonmedical/non- religious care.    Medicare payment for religious/nonmedical nursing personnel in a RNHCI, as other inpatient facilities, is a component of the per diem rate and is not separately payable.   Non-Covered Charges   Required -  The RHNCI must enter the total non- covered charges pertaining to the related revenue code, if any (e.g., religious items/services or religious activities performed by nurses or other staff, or convenience items that are not part of the Medicare daily interim payment rate.)   Examples of non -covered charges:    Non-covered religious items include but are not limited to religious publications, religious recordings, any equipment for the use of those recordings, any reproduction costs for these materials, and attendance at religious meetings.    Religious sessions with RNHCI staff or outside associates.   Expenses related to student programs/subsistence, staff education/training, travel, or relocation to be factored into the development of charges for covered patient care services.    Stays, items, and services that are not substantiated by appropriate documentation in the beneficiarys utilization review file or care record.    Convenience items (e.g., telephone, computer, beautician/barber).   Payer Identification   Required -  If Medicare is the primary payer, the RNHCI must enter "Medicare" on line A.  If Medicare is entered, this indicates that the RNHCI has developed for other insurance and has determined that Medicare is the primary payer.   All additional entries across line A supply information needed by the payer named.  If Medicare is the secondary or tertiary payer, the RNHCI may identify the primary payer on line A and enter Medicare information on line B or C as appropriate.   National Provider Identifier   Required -  The RNHCI enters their National Provider Identifier (NPI).   During Medicare processing, the NPI is matched to the RHNCIs CMS Certification Number (CCN).  RNHCI CCNs are composed of a 2 -digit state code and a 4 -digit provider identifier in the range 1990- 99.  Insureds Unique Identification  Required -  On the same lettered line (A, B, or C) that corresponds to the line on which Medicare payer information is shown, the RNHCI must enter the beneficiary's Medicare Health Insurance Claim Number.  The RNHCI must show the number as it appears on the  beneficiary's Medicare Card, Certificate of Award, Utilization Notice, Medicare Summary Notice, Temporary Eligibility Notice, or as reported by the Social Security Office.   Principal Diagnosis Code   Required -  While coding of a principal diagnosis is not consistent with the nonmedical nature of RNHCI services, the presence of diagnosis codes is a requirement for claims transactions under HIPAA.  To satisfy this requirement on claims with Statement Covers Through dates before implementation of ICD -10, the RNHCI may report ICD -9 code 799.9 (defined other unknown and unspecified cause).  To satisfy this requirement on claims with Statement Covers Through dates on or after the implementation of ICD -10, the RNHCI may report ICD -10 code R69 (defined illness, unspecified).   Other Diagnosis Codes   Required -  While coding of diagnoses is not consistent with the nonmedical nature of RNHCI services, the presence of diagnosis codes is a requirement for claims transactions under HIPAA.  To satisfy this requirement on claims with Statement Covers Through dates before the implementation of ICD -10, the RNHCI may report ICD -9 code V62.6 (defined refusal of treatment for reasons of religion or conscience).  To satisfy this requirement on claims with Statement Covers Through dates on or after the implementa tion of ICD -10, the RNHCI may report ICD -10 code Z53.1 (defined procedure and treatment not carried out because of patient's decision for reasons of belief).   The RNHCI reports no additional diagnosis codes in the remaining fields.  Similarly, RNHCIs do not use other fields relating to medical diagnoses and medical procedures.    The RNHCI reports no additional diagnosis codes in the remaining fields.  Similarly, RNHCIs do not use other fields relating to medical diagnoses and medical procedures.   Attending Provider   Required -  While the participation of an attending provider is not consistent with the nonmedical nature of RNHCI services, reporting an attending provider is a requirement for claims transactions under HIPAA.  To satisfy this requirement, the RNHCI must r eport the name and NPI of their director of nursing.   Remarks   Conditional -  The RNHCI may enter any remarks needed to provide information that is not shown elsewhere on the bill but which is necessary for proper payment.   Provider Representative Signature and Date  Required -  If using the hard copy claim, an RNHCI representative makes sure the claim record is complete and accurate before signing Form CMS -1450.  A stamped signature is acceptable on Form CMS -1450.  170.3 - RNHCI Claims Processing By the Medicare Contractor with RNCHI Specialty Workload  (Rev. 2654, Issued: 02- 08-13, Effective: 05 -09-13, Implementation, 05- 09-13)  Upon submission of a claim for RNHCI services, the contractor ensures that the submission contains the complete set of required data elements according to the instructions in 170.2.  The specialty contractor ensures that the submission does not contain da ta that is invalid, internally inconsistent or is not otherwise submitted in error.  If the submission is not found to be consistent with CMS instructions, it is returned to the RNHCI for correction.   Once the claim is found to satisfy CMS instructions, the contractor ensures the claim is not a duplicate of previously paid RNHCI services or does not demonstrate grounds for Medicare denial for any other reason.  If the claim appears appropriate for payment based on the specialty contractors initial processing, the claim is submitted to the CMS Common Working File (CWF) for approval.  The CWF system compares the claim submitted by the contractor to the eligibility and utilization data for the beneficiary that received the services.  The CWF ensures the beneficiary is eligible for Part A for the dates of service (since RNHCI services are exclusively a Part A benefit) and the beneficiary has utilization days remaining in their current inpatient spell of illness.  The CWF also compares the RNHCI claim to the beneficiarys file of RNHCI elections and claims.  If CWF does not identify any err or conditions on the RNHCI claim, an approval message is returned to the specialty contractor.   An RNHCI claim may be rejected by CWF if:    No RNHCI election period is present for the dates of service of the claim;    The RNHCI election period to which the claim would apply has been revoked (see section 180 for procedures that lead to revocation of the election);   The RNHCI election period to which the claim would apply has been cancelled; or   The service dates on the claim overlap previously paid claims for RNCHI services or other inpatient services that were processed by a Medicare contractor other than the specialty contractor.   Claims rejected for these reasons may not be corrected and returned by the RNHCI.  If the error condition can be resolved (for instance, by the resubmission of an election period cancelled in error), the RNHCI may submit a new original claim for the services.   Upon receipt of payment approval or rejection from CWF, the contractor may then process the claim to completion.  RNHCI claims are paid a daily interim rate as established for each RNHCI provider under TEFRA payment rules (see Pub. 15-2, Provider Reimbursement Manual, chapter 30).  The contractor makes RNHCI payments subject to the inpatient hospital cash deductible when applicable and, if services are for the 61st through 90th day of a benefit period or are for lifetime reserve days, subject to coinsurance (see Pub. 100- 01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 3, Sections 10.1 and 10.2).  170.3.1 - RNHCI Claims Not Billed to Original Medicare  (Rev. 2654, Issued: 02- 08-13, Effective: 05-09-13, Implementation, 05-09-13)  Health Plans   A beneficiary covered by a Medicare Advantage plan (e.g., Medicare health maintenance organization, preferred provider organization, competitive medical plan or other health care prepayment plans.) must have prior authorization from their plan before admission to a RNHCI to assure payment for a specified time period.  Continued stay reviews must be performed, submitted, and approved at designated intervals identified by the plan to assure coverage by the Medicare health plan.   In the case of billing a Medicare health plan, the RNHCI charges for inpatient services should not exceed the established interim TEFRA per diem payment amount available under Medicare Part A.  The Medicare health plan may obtain the current TEFRA per diem  rate information by calling the specialty contractor responsible for the involved RNHCI.   Medicaid   The State agency may obtain the current Medicare rate information by calling the Medicare contractor responsible for the RNHCI.   170.4 - Informing Beneficiaries of the Results of RNHCI Claims Processing  (Rev. 2654, Issued: 02- 08-13, Effective: 05-09-13, Implementation, 05-09-13)  Beneficiaries are informed of all Medicare payment determinations, including those for RNHCI services, via their monthly Medicare Summary Notice (MSN).  The complete set of messages used on the MSN can be found in chapter 21, section 50.42 of this manual.  The Medicare contractor with RHNCI specialty workload uses special messages on MSNs to reflect determinations specific to the RNHCI benefit.    If an RNHCI claim is denied because CWF did not find record of an RNHCI election in the beneficiaries record, the contractor uses MSN message 42.3.  This message reads: This service is not covered since you did not elect to receive religious nonmedical he alth care services instead of regular Medicare services.    If an RNHCI claim is denied because CWF found record of an RNHCI election in the beneficiarys record that had been revoked in writing, the contractor uses MSN message 42.5.  This message reads: This service is not covered because you requested in writing that your election to religious nonmedical health care services be revoked.   If an RNHCI claim is denied because CWF found record of an RNHCI election in the beneficiarys record that had been revoked because the beneficiary received nonexcepted medical care, the contractor uses MSN message 42.4.  This message reads: This service is not covered because you received medical health care services which revoked your election to religious nonmedical health care services.  180 - Processing Claims For Beneficiaries With RNHCI Elections by Contractors Without RNHCI Specialty Workloads  (Rev. 11963, Issued:04 -20-23, Effective: 10-01-23, Implementation, 10-02-23)  While elections and claims for RNHCI services are processed by the Medicare contractor with RNHCI specialty workload, all Medicare contractors  (below non- specialty contractors) must understand the nature and purpose of the RNHCI election and the definitions of excepted and non- excepted care defined in Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 1, Section 130.  Non- specialty contracto rs may  find it advisable to have an identified specialist (or specialists) familiar with excepted and nonexcepted care used in the review of beneficiaries with RNHCI elections, since this process is so unlike other Medicare claims processes.   Beneficiaries may revoke their RNHCI election by submitting a written revocation request to Medicare, but this is rare.  Far more commonly, beneficiaries revoke the election simply by receiving nonexcepted medical services and requesting Medicare payment f or those services.  Any non- specialty contractor may receive a claim for services for a beneficiary with an RNHCI election currently in place.  This section provides instructions to non- specialty contractors for the handling of such claims.  Upon receipt of a claim for payment, non- specialty contractors will not be aware that the beneficiary has an RNHCI election in place and will process the claim normally to the point of transmitting the claim to CWF.  The CWF searches beneficiary records fo r all claims to determine whether an RNHCI election is found.  If an election is found, CWF takes one of two actions on a claim for non- RNHCI services:    If the claim is for DME, or prosthetic/orthotic devices, CWF will accept the DMEPOS claim and revoke the RNHCI election.  All DMEPOS claims are treated as nonexcepted medical care.    If the claim is for COVID -19 vaccine services and no other covered services, CWF will accept the claim and leave the RNCHI election in place.  All COVID -19 vaccines and their administrations are treated as excepted medical care.    If the claim is for any other Medicare covered services, CWF initially rejects it to the non- specialty contractor.  The non- specialty contractor must determine whether the care was excepted or nonexcepted.  The claim must never be automatically denied.  The RNHCI election revocation does not interfere with the b eneficiarys ability to seek other Medicare services within the limits of their Medicare coverage.