(Medicare Claims Processing Manual)

If the other insurer requires a denial from Medicare before making payment for these services, a denial notice cannot be processed by Medicare claims processing systems. Medicare systems require submission of a Notice of Election (NOE) before any RNHCI claims, including claims for denial, can be processed.  The RNHCI may request in writing a denial notice from the Medicare contractor.  The written request must describe the reason the beneficiary does not qualify for Medicare coverage.  It must also describe the specific services that will be provided to the beneficiary.  In response, the contractor will provide the RNHCI with a manual denial letter.  This letter may then be submitted to a secondary insurer as evidence of a prior Medicare denial .  170.1.2 - Revocation of RNHCI Election  (Rev. 2654, Issued: 02- 08-13, Effective: 05-09-13, Implementation, 05-09-13)  Under 1821(b)(3), a beneficiary may revoke an election in writing or by receiving nonexcepted medical care.  Once an election has been revoked, Medicare payment cannot be made to an RNHCI unless a new valid election is filed.  The RNHCI revocation does not interfere with the beneficiarys ability to seek other Medicare services within the limits of his/her Medicare coverage.  Multiple revocations may affect the beneficiarys ability to access the RNHCI benefit in the future (see Pub. 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 130.2.2).  Written revocations received from a beneficiary must be filed by the RHNCI with their Medicare contractor and a copy retained by the RNHCI provider.  Revocations may be filed using the same format as elections, indicating a revocation in the type of bill code.  See section 170.1.3 below for details.  170.1.3 - Completion of the Notice of Election for RNHCI  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of ICD -10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)  Elections, revocations and cancellations of elections may be submitted to the contractor via the paper Form CMS-1450 or via the contractors Direct Data Entry (DDE) system.  Election transactions are not covered transaction under the Health Insurance Porta bility and Accountability Act of 1996 (HIPAA) and therefore the HIPAA standard claim transaction is not required.  Additionally, the HIPAA standard claim transaction (ASC X12 837 institutional claim format) does not support the data requirements of these transactions.   This section gives detailed information only for items required for the notice of election and related transactions.  The RHNCI does not need to complete items not listed.  Provider Name, Address, and Telephone Number   Required -  The minimum entry is the RNHCIs name, city, State, and ZIP code.  The post office box number or street name and number may be included.  The State may be abbreviated using standard post office abbreviations.  Five - or 9-digit ZIP codes are acceptable.  The RNHCI uses the information to reconcile provider number discrepancies.  Phone and/or FAX number s are desirable.   Type of Bill   Required -  The RNHCI enters the 3 -digit numeric type of bill code.  The first digit identifies the type of facility.  The second digit classifies the type of care.  The third digit (commonly referred to as a frequency code) indicates in this instance the nature of the election related transaction.   The RNHCI enters type of bill 41A, 41B, or 41D as appropriate.   Valid codes for RNHCI elections:       1st Digit -  Type of Facility   4- Religious Nonmedical Health Care Institution       2nd Digit -  Classification (Special Facility)   1- Inpatient (Part A)       3rd Digit -  Frequency   A - RNHCI election notice   B - RNHCI revocation notice   D - Cancellation   The RNHCI submits type of bill 41D to the specialty contractor as a cancellation of a previously submitted notice of election or notice of revocation, when it was submitted in error.  In situations where the RNHCI is correcting a previously submitted date, they submit a new type of bill 41A to the contractor for processing.   Patients Name   Required -  The RNHCI enters the patients name with the surname first, first name, and middle initial, if any.   Patients Address   Required -  The RNHCI enters the patients full mailing address including street name and number, post office box number or RFD, city, State, and ZIP code.   Patients Birth Date   Required -  (If available) The RNHCI enters the month, day, and year of birth.  If the date of birth cannot be obtained after a reasonable effort, the field will be zero- filled.   Patients Sex   Required -  The RNHCI enters an M for male or an F for female.   Admission Date   Required -  The RNHCI enters the date of the election, revocation or cancellation.  In no instance should the date be prior to July 1, 2000.  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 Name   Required -  The RNHCI enters the beneficiarys name on line A if Medicare is the primary payer.  The RNHCI enters the name as on the beneficiarys Medicare card.  If Medicare is the secondary payer, the RNHCI enters the beneficiarys name on line B or C, as  applicable, and enters the insureds name on line A.  Insureds Unique Identification  Required -  On the same lettered line (A, B, or C) that corresponds to the line on which Medicare payer information is, the RNHCI enters the patients HICN.  The RNHCI enters the number as it appears on the patients Medicare Card, Social Security Award Certificate, Utilization Notice, Medicare Summary Notice, Temporary Eligibility Notice, etc., or as reported by the Social Security Office.   170.1.4 - Common Working File (CWF) Processing of Elections, Revocations and Cancelled Elections  (Rev. 2654, Issued: 02- 08-13, Effective: 05 -09-13, Implementation, 05- 09-13)  The Medicare contractor with RNHCI specialty workload submits all RNHCI election, revocations and cancelled elections to CWF for approval.  The CWF will notify the contractor that these transactions were received and accepted.   The CWF uses these records to maintain a beneficiary file of all RNHCI beneficiary elections and revocations.  This file is used in processing claims for RNHCI services (see section 170.3 below) and for other Medicare services (see section 180).   CWF rejects any notices of revocations or cancellations when:    CWF history shows no RNHCI elections are on file;    The submitted dates do not match the elections on file;    The revocation date is prior to the date of the election;    The election in question has already been revoked or cancelled; or    CWF history indicates an RNHCI claim has been processed during the election period to which the revocation or cancellation applies.  If these claims were submitted in error, the RNHCI must cancel the claims prior to resubmitting the revocation or cancellat ion.  170.2 - Billing Process for RNHCI Services  (Rev. 851, Issued:  02- 10-06; Effective/Implementation Dates:  05 -11-06)  170.2.1 - When to Bill for RNHCI Services  (Rev. 2654, Issued: 02- 08-13, Effective: 05 -09-13, Implementation, 05- 09-13)  RNHCIs submit claims to their Medicare contractor in the following situations:   At the time of beneficiary's discharge, or death.    At the time the beneficiary's benefits are exhausted    On an interim basis monthly.  RNHCIs submit a claim even where the charges do not exceed the beneficiary's deductible.  See section 40 for instructions regarding reporting of utilization days.  170.2.2 - Required Data Elements on Claims for RNHCI Services  (Rev. 3075, Issued; 09- 24-14, Effective: 11 -12-14, ICD -10: Upon Implementation of ICD- 10, Implementation: 11- 12-14, ICD -10: Upon Implementation of ICD -10)  The Social Security Act at 1862 (a)(22) requires that all claims for Medicare payment must be submitted in an electronic form specified by the Secretary of Health and Human Services, unless an exception described at 1862 (h) applies.  The electronic form  required for billing RNHCI claims is the ASC X12 837 institutional claim transaction.  Since the data structure of the ASC X12 837 institutional claim transaction is difficult to express in narrative form and to provide assistance to small providers excepted from the electronic claim requirement, the instructions below are given relative to the Form CMS -1450 paper claim.   Both the electronic claim transaction and the paper claim form are suitable for use in billing multiple third party payers.  This section details only those data elements required for Medicare billing.  When RNHCIs are billing multiple third parties, they complete all items required by each payer who is to receive a claim for the services.   Provider Name, Address, and Telephone Number   Required -  The RNHCI must enter their name, city, State, and ZIP Code.  The post office box number or street name and number may be included.  The State may be abbreviated using standard post office abbreviations.  Five or 9- digit ZIP Codes are acceptable.   This information is used in connection with the Medicare provider number to verify provider identity.  Phone/Fax numbers are desirable.   Patient Control Number/Medicare Record Number  Optional -  The RNHCI may report a beneficiary's control number if they assign one and need it for association and reference purposes.   Type of Bill   Required -  This 3 -digit alphanumeric code gives three specific pieces of information.  The first digit identifies the type of facility.  The second classifies the type of care.  The third indicates the sequence of this claim in this particular episode of care.  It is a "frequency" code.   Valid codes for RNHCI claims:       1st Digit -Type of Facility  4 - Religious Nonmedical Health Care Institution       2nd Digit Classification (Except Clinics and Special Facilities)   1 - Inpatient (Part A)       3rd Digit -Frequency     Definition       0-Nonpayment/zero claims   Use when you do not anticipate payment from the payer for the bill but are merely informing the payer about a period of nonpayable confinement or termination of care.  The "Through" date of this bill is the discharge date for this confinement.  Nonpayment bills are required only to extend the "spell of illness."  See code 71 below.      l-Admit Through Discharge Claims  Use for a bill encompassing an entire inpatient confinement for which you expect payment from the payer or for which Medicare utilization is chargeable.       2-Interim- First Claim  Use for the first of an expected series of payment bills for the same confinement or course of treatment for which Medicare utilization is chargeable.       3-Interim- Continuing Claim  Use when a payment bill for the same confinement or course of treatment has been submitted, further bills are expected to be submitted and Medicare utilization is chargeable.       4-Interim- Last Claim   Use for a payment bill which is the last of a series for this confinement or course of treatment when Medicare utilization is chargeable.  The "Through" date of this bill is the discharge date for this confinement.       7-Replacement of Prior Claim  Use to correct (other than late charges) a previously submitted bill. This is the code applied to the corrected or "new" bill.      8-Void/Cancel of a Prior Claim  This code indicates the bill is an exact duplicate of an incorrect bill previously submitted. Enter a code "7" (Replacement of Prior Claim) showing the correct information.   Statement Covers Period (From -  Through)   Required -  The RNHCI must enter the beginning and ending dates of the period covered by this bill.  Enter the date of discharge or the date of death in the space provided under "Through."  The statement covers period may not span 2 accounting years.   Patient's Name   Required -  The RNHCI must enter the beneficiary's last name, first name, and middle initial, if any.   Patient's Address   Required -  The RNHCI must enter the beneficiary's full mailing address, including street number and name, post office box number or RFD, City, State, and ZIP Code.  Patient Birth Date