(Medicare Claims Processing Manual)

 Services determined not to be medically  necessary and the beneficiary was not informed in writing, in advance, that the services may not be paid;    The provider failed to tell the beneficiary if the diagnostic test was purchased, from whom it was purchased, the acquisition cost of the purchased test, or the cost of the professional component;    Missing information such as ICD -9, UPIN, etc.;   The charge was denied as a duplicate;    The service was part of a major surgery, test panel or bundled code; or    The service was denied/reduced because of utilization reasons.  L. Beneficiary responsibility  L = J + K Display this amount in the Maximum You May Be Billed column for service lines on assigned claims.  Claims submitted with a beneficiary paid amount require additional calculations.  See Subsection F below.    Maximum You May Be Billed Column -  Unassigned Claims  The following chart is used to display the Maximum You May Be Billed amounts for each service line on unassigned claims other than those that have a Medicare secondary payment less than the amount Medicare would have paid if it were primary.   Calculations for Completing Maximum You May Be Billed Column - Unassigned Claims  Instructions/Source of Dollar Amount for Calculations  A. Of the total charges  The billed amount for the service line.  B. Approved amount  The service line approved amount.  C. Amount exceeding limiting charge  For unassigned services subject to the limiting charge, this is the actual dollar amount by which the limiting charge is exceeded.  If the amount is less than $1.00, C = 0.  Do not include services being reduced or denied for any of the conditions under E.  D. Net Responsibility  D = A - C. Calculations for Completing Maximum You May Be Billed Column - Unassigned Claims  Instructions/Source of Dollar Amount for Calculations  E. Less charges beneficiary is not liable for  This step represents charges that were denied or reduced and the beneficiary is not liable for the denial or the reduction.  Include dollar amounts for denials or reductions such as:    Services determined not to be medically necessary, and the beneficiary was not informed in writing in advance that the services may not be paid;    The provider failed to tell the benefic iary if the diagnostic test was purchased, from whom it was purchased, the acquisition cost of the purchased test, or the cost of the professional component;    The claim did not have an ICD -9 code listed, or the service was not linked to an ICD-9 code;    The charge was denied as a duplicate;    The service was part of a major surgery, test panel, or bundled code;    The service was denied because of utilization reasons; or    Rebundling  of services when the minor service was paid before the major service was billed.  Use the amount allowed for the minor service in step E, or Reductions due to coverage.  F. Beneficiary Responsibility  F = D - E Display this amount in the Maximum You May B e Billed column for unassigned claims.  Claims submitted with a beneficiary paid require additional calculations, therefore, proceed to 10.3.10.2(f) .  Display of the Medicare Paid You and Medicare Paid Provider Columns for MSP Claims   Medicare secondary payment is computed by the MSP pay module based on claim totals.  However, the MSN displays calculations by service line.  In order to complete the Medicare Paid Provider and Medicare Paid You columns for MSP claims, the MAC must apportion the total amount Medicare paid on the claim among the approved service lines.   For the first approved service line, show  the lesser of 80 percent (50 percent if the outpatient psychiatric limit applies, or 100 percent for services paid at 100 percent) of the Medicare approved amount, less any deductible applied, or the amount Medicare actually paid on the claim.   For the se cond approved service line, show the lesser of:    80 percent (50 percent if the outpatient psychiatric limit applies, or 100 percent for services paid at 100 percent) of the Medicare approved amount less any deductible applied, or    The actual amount Medicar e paid on the claim minus the amount shown under Medicare Paid for the prior approved service lines.  Continue on following lines in this manner until the entire Medicare secondary payment for the claim has been exhausted.   Display of the Maximum You May Be Billed Column for MSP Claims   1. Assigned Claims   If the Medicare secondary payment plus the amount the primary insurer paid equals or exceeds the Medicare approved amount, display $0.00 in the Maximum You May Be Billed column for each approved ser vice line.   If the Medicare secondary payment plus the amount the primary insurer paid is less than the Medicare approved amount, A/B MACs (B)/DME MACs calculate the total beneficiary responsibility for approved services by subtracting the sum of the prima ry insurers payment and the Medicare secondary payment from the total Medicare approved amount for those services.   Amount Medicare Approved on Claim -  (Primary Insurer Payment + Medicare Payment) = Total Beneficiary Responsibility   For the first approved service line, A/B MACs (B)/DME MACs show the lesser of 20 percent (50 percent if the outpatient psychiatric limit applies) of the Medicare approved amount or the beneficiarys total responsibility for all approved services on the claim.  For the second approved service line, A/B MACs (B)/DME MACs show the lesser of 20 percent (50 percent if the outpatient psychiatric limit applies) of the approved amount for the line or the beneficiarys total responsibility for approved services minus the amount shown for  the prior approved service line.   Continue in this manner until the entire beneficiary responsibility has been exhausted.  Enter $0.00 in the Maximum You May Be Billed column for denied services for which the beneficiary is not liable.   Enter the amount  charged in the Maximum You May Be Billed column for denied services for which the beneficiary is responsible.   NOTE:  If there is an obligated to accept amount submitted on the claim, and that amount is greater than zero but less than the Medicare appr oved amount, use the obligated to accept amount in place of the Medicare approved amount when performing the above calculations.  2. Unassigned Claims   The amount in the Maximum You May Be Billed column for approved services is the amount charged or the limiting charge, whichever is less.   NOTE: If there is an obligated to accept amount submitted on the claim and that amount is greater than zero but less than the amount charged or the limiting charge, use the obligated to accept amount when performing this calculation.  Enter $0.00 in the Maximum You May Be Billed column for denied services for which the beneficiary is not liable.  Enter the amount charged in the Maximum You May Be Billed column for denied services for which the beneficia ry is responsible.  Display of the Maximum You May Be Billed Column for Claims Submitted with a Beneficiary Paid Amount   1. Assigned Claims   If an assigned claim is submitted with a beneficiary paid amount, the amount(s) in the Maximum You May Be Billed  column will be reduced by the amount the beneficiary prepaid the provider.   Apply the beneficiary paid amount as indicated below to each service line sequentially until the beneficiary paid amount is reduced to zero or all service lines have been conside red.  Step 1: Subtract the amount of the beneficiary check, if any, from the patient amount submitted on the claim.  Use the difference as the new patient paid amount.  If there was no check to the beneficiary, use the patient paid amount submitted on the claim for remaining steps.   Step 2: If the new patient paid amount is less than or equal to the amount calculated for the Maximum You May Be Billed column, subtract the new patient paid amount from the original Maximum You May Be Billed amount, and dis play the difference in the Maximum You May Be Billed column for that service line.   Step 3: If the new patient paid amount is greater than the amount calculated for the Maximum You May Be Billed column, subtract the original Maximum You May Be Billed  amount for the first service line from the new patient paid amount, and show zero in the Maximum You May Be Billed column.   Repeat these steps with any remaining beneficiary paid amounts.   2. Unassigned Claims   If an unassigned claim is submitted with a  beneficiary paid amount, the amount(s) in the Maximum You May Be Billed column will be reduced by the amount the beneficiary prepaid the provider.  Apply the beneficiary paid amount for each service line sequentially until the beneficiary paid amount is  reduced to zero or all service lines have been considered.   Step 1:  If the amount the beneficiary paid is less than or equal to the amount calculated for the Maximum You May Be Billed column, subtract the amount the beneficiary paid from that amount, a nd display the difference in the Maximum You May Be Billed column for that service line.  Step 2:  If the amount the beneficiary paid amount is less than or equal to the amount calculated for the Maximum You May Be Billed column, subtract the Maximum You May Be Billed amount for the first service line from the amount the beneficiary paid, and show zero in the Maximum You May Be Billed column for that service line.   Repeat these steps with any remaining beneficiary paid amounts.   If there is a balance after all service lines have been considered on unassigned claims, that amount is what the beneficiary overpaid the provider.  A/B MACs (B)/DME MACs have the option of printing claim level message 34.3 in this situation if their system permits.   Print message 34.2 on assigned claims when the beneficiary paid amount does not exceed coinsurance and deductible and for all unassigned claims submitted with a beneficiary paid amount.  Display of the Medicare Paid You Column for Unassigned Claims with a Previous Overpayment Amount Withheld   The Medicare Paid You column should show the act ual amount that would have been paid if no previous overpayment had been withheld from the check issued to the beneficiary.  Use message 32.1 to show the amount by which the check is reduced to recover an overpayment from the beneficiary.   Display of the Medicare Paid You Column for Assigned and Unassigned Adjustment Claims   Show all service lines for the adjustment claim.  The Medicare Approved and Medicare Paid columns will display the same allowed and paid amounts as were shown on the original MSN for service lines that are not subject to adjustment.   The Medicare Approved and Medicare Paid columns for adjusted service lines will show the tota l combined amount approved and paid for both the original and adjusted claim.  Likewise, Claim Total lines for adjusted claims will reflect the combined total amounts approved and paid for the original and adjusted claim.  The Maximum You May Be Billed column will show the beneficiarys total responsibility.  The MAC uses message 31.13 on all adjustments where a partial payment was previo usly made.   C. Suppression of Claims From MSNs   A/B MACs (A), (B), (HHH), and DME MACs have the option to suppress claims from MSNs when all  of the following three conditions apply:    The claim is a coordination of benefits (crossover) claim for Medicaid;   There is no resulting beneficiary liability; and   Suppression of the MSN is cost effective.   In addition, if the MACs system denies an exact duplicate of a claim, the MAC may suppress the claim from the MSN.  An exact duplicate claim is one in which every f ield of the duplicate claim matches every field of the original claim.   Since appeal rights are not affected, do not display claims on MSNs for services paid at 100 percent of the fee schedule where no deductible or coinsurance is applied, e.g., diagnostic  laboratory services.  If other services on that claim will appear on the MSN, include all services being paid.   Upon the beneficiarys request, create and send MSNs for previously suppressed claims.   Do not suppress claims from MSNs when any of the follow ing conditions apply:    One or more services were denied because one of the exclusions from Medicare coverage in 1862(a)(1)  of the Social Security Act (the Act) applies;    The claim is denied as not filed within the time limits required by 1842(b)(3)  of the Act;    The claim is denied in full or in part because the beneficiary was not enrolled in Part A or B of Medicare when the services in question were provided; or    An initial determination is made on a claim not later than the 45 -day period beginning on the date the A/B MAC (A), (B), (HHH), or DME MAC receives a claim.  10.3.8 - Specifications for Se ction 4 (Last Page): Denials and Appeals  (Rev. 10180, Issued: 06- 12-2020, Effective: 10- 01-2020, Implementation: 10-05-2020)