(Medicare Claims Processing Manual)

 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.   The process for non- specialty contractors to follow in responding to this CWF edit is unique among Medicare claims processes.  A determination must be made whether the beneficiarys RNHCI election should be revoked.  Therefore, unlike other CWF rejects whi ch are processed in an automated fashion, claims rejected by CWF due to the presence of an RNHCI election must be suspended and developed to determine if the beneficiary received excepted care.   At differing points in time, this review consisted of a request for medical records or a series of telephone contacts but these methods were found too workload intensive.  In response to a CWF reject due to the presence of an RNHCI election, non -specialty contractors must issue a simple development letter asking the provider of services to respond in a yes or no fashion to three questions:    Whether the beneficiary paid for the services out of pocket in lieu of requesting payment from Medicare;    Whether the beneficiary was unable to make his/her beliefs and wishes known before receiving the services that have been billed; and    Whether, for a vaccination service, the vaccination performed was required by a government jurisdiction.   Each non- specialty contractor may develop the wording and format of this letter based on their experience effectively communicating with their community of providers.   The purpose for this development letter is to determine whether the care received is excepted (leaving the election intact) or whether it is nonexcepted (causing a revocation of the RNHCI election).  Provider responses of No to all questions in the lette r will determine that the services are found to be non- excepted care.  Provider responses of Yes to the questions regarding inability to make beliefs known or regarding required vaccinations will determine that the services are found to be excepted care.  Unless reasons to deny these claims are found during the course of claims processing, these claim will normally be paid.  A provider response of Yes to the question regarding the beneficiarys paying out of pocket will determine that the services are fo und to be excepted care, but the claim for payment for medical care must be denied.  The claim must be denied because the beneficiary has not made a request for Medicare payment.  The beneficiary has accepted liability for these services in order to protec t their RNHCI election.   Once the non- specialty contractor makes this determination of whether the care is excepted or nonexcepted, the claim record is annotated accordingly (see section 180.1 below) and returned to CWF.  The claim will be approved for payment and if the care was found to be nonexcepted CWF will cause the beneficiarys RNHCI election to be revoked.   In the event that the provider does not reply timely to the development letter, non- specialty contractors must make an excepted/nonexcepted determination based on the evidence presented by the claim itself.  Non- specialty contractors shall apply the same t imeliness standard to these responses as to all other documentation requests.  If the claim contains durable medical equipment or prosthetic/orthotic devices, the non- specialty contractor may make a determination of nonexcepted care on that basis alone.  A ll such claims are treated as nonexcepted care.  For all other claims, non -specialty contractor staff with a clinical background must make their best determination based on the diagnoses and procedures reported on the claim whether the services were except ed or nonexcepted care.  In cases where the determination cannot be made with certainty but there is some reason to suspect services were nonexcepted care, the non -specialty contractor shall make a determination of nonexcepted care and annotate the claim r ecord accordingly.   Determinations must be made within the earlier of 30 days of receipt of the providers response or 30 days of the end of the timely response period.   The importance of the development of these claims lies in its effect on the beneficiary.  If the claim for medical care is denied improperly based on the presence of the RNHCI election, the beneficiary will incur liability in error and may experience finan cial hardship.  Similarly, it is important that the review result in accurate determinations of nonexcepted care since repeated revocations of this benefit can have an impact on the beneficiarys right to access the RNHCI benefit in the future.   180.1 - Recording Determinations of Excepted/Nonexcepted Care on Claim Records  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)   Once the excepted/nonexcepted care determination is made, the non -specialty contractor resubmits the claim to CWF using the following indicators to record the determination:    Indicator 1 -  for excepted care; or    Indicator 2 -  for nonexcepted care.   NOTE : Indicator 0 (zero) presents no entry.   The following are the fields and locations for the excepted and nonexcepted indicators on the CWF record types:   Record  Location  Field  Size HUIP (IP hospital/SNF Claim)  84 1 823 HUOP (Outpatient)  64 1 778 HUHC (Hospice)  64 1 778 HUHH (Home Health)  64 1 778 HUBC (A/B MAC (B) Claim)  13 1 57  The screen field corresponding to these CWF fields may vary depending on the Medicare shared system in use at a contractors location.  Non- specialty contractors may contact their shared system maintainer if necessary to determine the correct screen location to use for excepted/nonexcepted care indicators.   If a claim is resubmitted with a 0 excepted care indicator in error, CWF will again reject the claim.  Upon receipt of the resubmitted claim with a valid 1 or 2 entry, CWF will approve it for payment and revoke the beneficiarys election if the care received was nonexcepted.  CWF will not notify either the specialty contractor or the non- specialty contractor of any revocations as a result of claims received for nonexcepted care.  Any subsequent RNHCI claims processed at the contractor with RNHCI specialty workload will be not approved for payment by CWF unless the beneficiary files a new election following the prescribed time intervals between elections.   If development to make the excepted/nonexcepted care determination discovered that the beneficiary paid out of pocket for the services and the claim for payment for medical care must be denied as a result.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: PR  CARC: 96  RARC: MA47  MSN: N/A  180.2 - Informing Beneficiaries of the Results of Excepted/Nonexcepted Care Determinations by the Non -specialty Contractor  (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.   Non-specialty contractors use special messages on MSNs to reflect determinations specific to excepted or nonexcepted care.    If a determination of excepted care is made, the non -specialty contractor uses MSN message 42.1.  This message reads: You received medical care at a facility other than a religious nonmedical health care institution but that care did not revoke your elect ion to receive benefits for religious nonmedical health care.    If a determination of nonexcepted care is made, the non -specialty contractor uses MSN message 42.2.  This message reads: Since you received medical care at a facility other than a religious nonmedical health care institution, benefits for religious nonmedical health care services has been revoked for these services unless you file a new election.   If development to make the excepted/nonexcepted care determination discovered that the beneficiary did not request Medicare payment, but instead paid for the services out of pocket, the non- specialty contractor uses MSN message 16.41.  This message reads: Payment is being denied because you refused to request reimbursement under your Medicare benefits.   190 - Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  190.1 - Background  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  This section and its subsections provide instructions about the IPF PPS. The IPF PPS replaces existing reasonable cost -based payments subject to Tax Equity and Fiscal Responsibility Act (TEFRA) limits under section 1886 (b) of the Social Security Act (the Act) for discharges occurring on and after the first day of the IPF's first cost reporting period beginning on or after January 1, 2005.  The IPF PPS, codified at 42 CFR 412, Subpart N, provides payment for inpatient psychiatric treatment when provided to an inpatient in psychiatric hospitals and distinct part psychiatric units of acute care hospitals and critical access hospitals (CAHs).   190.2 - Statutory Requirements  (Rev. 1101, Issued: 11- 03-06, Effective: 01-01-05, Implementation: 12-04-06)  Section 124 of the Medicare, Medicaid, and SCHIP (State Children's Health Insurance Program) Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L.106-113), mandated that the Secretary:  (1) develop a per diem PPS for inpatient hospital services furnished in psychiatric hospitals and psychiatric units; (2) include in the PPS an adequate patient classification system that reflects the differences in patient resource use and costs among psychiatric hospitals and psychiatric units; (3) maintain budget neutrali ty; (4) permit the Secretary to require psychiatric hospitals and psychiatric units to submit information necessary for the development of the PPS; and (5) submit a report to the Congress describing the development of the PPS.  Section 124 of the BBRA also required that the IPF PPS be implemented for cost reporting periods beginning on or after October 1, 2002.  The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P. L. 108-173), section 405(g) extended the IPF PPS to distinct part psychiatric units of CAHs, effective for  cost reporting periods beginning on or after October 1, 2004.  190.3 - Affected Medicare Providers  (Rev. 11396, Issued:05-04-22, Effective:10-01-22, Implementation:10-03-22)  Psychiatric hospitals and distinct part psychiatric units of acute care hospitals and CAHs are included in the IPF PPS and are referred to in these instructions as inpatient psychiatric facilities or IPFs.   The regulations at 42 CFR 412.402 define an IPF as a hospital that meets the requirements specified in  42 CFR 412.22, 42 CFR 412.23(a) , 42 CFR 482.60 , 42 CFR 482.61, and 42 CFR 482.62 , and units that meet the requirements specified in 42 CFR 412.22, 42 CFR 412.25, and 42 CFR 412.27 .  IPFs are certified under Medicare as inpatient psychiatric hospitals, which means an institution that is primarily engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill patien ts, maintains clinical records necessary to determine the degree and intensity of the treatment provided to mentally ill patients, and meets staffing requirements sufficient to carry out active programs of treatment for individuals who are furnished care in the institution.  A distinct part psychiatric unit may also be certified if it meets the clinical record and staffing requirements in 42 CFR 412.27 which mirror the requirements for a psychiatric hospitals in 42 CFR 482.60, 42 CFR 482.61 and 42 CFR 482.62 .