(Medicare Claims Processing Manual)

17) The Medicare contractor shall finalize the cost report, issue a NPR and make the necessary adjustment from or to the provider.   18) After determining the total outlier reconciliation amount and issuing a NPR, Medicare contractors shall restore the CCR(s) to their original values (that is, the CCRs used to pay the claims) in the applicable provider records in the PSF to ensure an accurate history is maintained. Specifically, for hospitals paid under the LTCH PPS, Medicare contractors shall enter the original CCR(s) in PSF field 25 -Operating Cost to Charge Ratio.  If the Medicare contractor has any questions regarding this process it should contact the Central Office, via email at outliersIPPS@cms.hhs.gov.   Table 1:  Data Elements for FISS Extract   List of Data Elements for FISS Extract  Provider #  Health Insurance Claim (HIC) Number  Document Control Number (DCN)  Type of Bill  Original Paid Date  Statement From Date  Statement To Date  Original Reimbursement Amount (claims page 10)  Revised Reimbursement Amount (claim page 10)  Difference between these amounts  Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Difference between these amounts  Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Difference between these amounts  Original Outlier Amount (Value Code 17)  Revised Outlier Amount (Value Code 17)  Difference between these amounts  Original DSH Amount (Value Code 18)  Revised DSH Amount (Value Code 18)  Difference between these amounts  Original IME Amount (Value Code 19)  Revised IME Amount (Value Code 19)  Difference between these amounts  Original New Tech Add -on (Value Code 77)  Revised New Tech Add -on (Value Code 77)  Difference between these amounts  Original Device Reductions (Value Code D4)  Revised Device Reductions (Value Code D4)  Difference between these amounts  Original Hospital Portion (claim page 14)  Revised Hospital Portion (claim page 14)  Difference between these amounts  Original Federal Portion  (claim page 14)  Revised Federal Portion  (claim page 14)  List of Data Elements for FISS Extract  Difference between these amounts  Original C TOT PAY (claim page 14)  Revised C TOT PAY (claim page 14)  Difference between these amounts  Original C FSP (claim page 14)  Revised C FSP (claim page 14)  Difference between these amounts  Original C OUTLIER (claim page 14)  Revised C OUTLIER (claim page 14)  Difference between these amounts  Original C DSH ADJ (claim page 14)  Revised C DSH ADJ (claim page 14)  Difference between these amounts  Original C IME ADJ (claim page 14)  Revised C IME ADJ (claim page 14)  Difference between these amounts  Original Pricer Amount  Revised Pricer Amount  Difference between these amounts  Original PPS Payment (claim page 14)  Revised PPS Payment (claim page 14)  Difference between these amounts  Original PPS Return Code (claim page 14)  Revised PPS Return Code (claim page 14)  DRG  MSP Indicator (Value Codes 12 -16 & 41-43 - indicator indicating the claim is MSP; Y = MSP, blank = no MSP  Reason Code  HMO -IME Indicator  Filler   160 - Necessary Changes to Implement Special Add -On Payments for New Technologies (Rev. 1, 10-01-03) A-02-124  160.1 - Special Add -On Payments For New Technologies (Rev. 1, 10-01-03)  Section 533(b) of the Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA) amended section 1886(d)(5) of the Act to add subparagraphs (K) and (L) and establish a process of identif ying and ensuring adequate payment for new medical services and technologies under Medicare. In the September 7, 200l, final rule (66 FR 46902), CMS established that cases using approved new technology would be appropriate candidates for an additional payment when: the technology represents an advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries; the payment for such cases can be demonstrated to be inadequately paid otherwise under the diagnosis -related group (DRG) system; and data reflecting the costs of the technology would be unavailable to use to recalibrate the  DRG weights.  Under 42 CFR 412.88 of the regulations, an add -on payment is made for discharges involving approved new technologies, if the total covered costs of the discharge exceed the DRG payment for the case (including adjustments for indirect medical education (IME) and disproportionate share hospitals (DSH) but excluding outlier payments). PRICER calculates the total covered costs for this purpose by applying the cost -to-charge ratio (that is used for inpatient outlier purposes) to the total covered costs of the discharge. Payment for eligible cases is equal to:   The full DRG payment (see example 1  that follows); plus    The lesser of   1. 50 percent of the costs of the new medical service or technology (see example 2); or  2. 50 percent of the amount by which the total covered costs (as determined above) of the case exceed the DRG payment (see example 3 ); plus    Any applicable outlier payments if the costs of the case exceed the DRG, plus adjustments for IME and DSH, and any approved new technology payment for the case plus the fixed loss outlier threshold. The costs of the new technology are included in the deter mination of whether a case qualifies for outliers.   This instruction implements the above payment mechanism into the claims processing systems.   Below are three illustrative examples of this policy for cases involving an eligible technology estimated to cost $3,000 in a DRG that pays $20,000.  Example One   Applying the hospitals cost -to-charge ratio to the total covered charges for the case, it is determined the total cost for the case is $19,000. Medicare would pay $20,000, the full DRG payment. Even though the case involved a new technology eligible for add- on payments, the total covered costs of the case did not exceed the DRG payment, therefore, no additional payment is made.   Example Two:   Applying the hospitals cost -to-charge ratio to the total covered charges for the case, it is determined the total cost for the case is $25,000. Because, in this case, 50 percent of the costs of the new medical service or technology is less than 50 percent  of the amount by which the total covered costs (as determined above) of the case exceed the DRG payment, Medicare would pay 50 percent of the costs of the new technology (in addition to the DRG payment). Therefore, for this case, Medicare would pay $21,500 (the DRG payment of $20,000 plus one -half of $3,000, the estimated cost of the new technology).  Example Three:   Applying the hospitals cost -to-charge ratio to the total covered charges for the case, it is determined the total cost for the case is $22,000. Medicare would pay one -half of the amount by which the costs of the case exceed the DRG payment, up to the esti mated cost of the new technology. Therefore, for this case, Medicare would pay $21,000 (the DRG payment of $20,000 plus one -half of the costs above that amount).   160.1.1 - Identifying Claims Eligible for the Add -On Payment for New Technology  (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)   Technologies eligible for add- on payments are identified based on the applicable codes from the International Classification of Diseases, Clinical Modification.  Claims submitted with an ICD code indicating that a new technology was involved in the treatme nt of the patient is then eligible for add -on payments as described above.   The system maintainers pass (if present) the "principal" and up to twenty four "other procedure" codes to PRICER. If an eligible code is present, PRICER calculates an add -on payment if appropriate.   Additionally, the National Uniform Billing Committee has approved value code 77 for use on the ASC X12 837 institutional claim or Form CMS -1450 for A/B MAC (A) use only, defined as New Technology Add- On Payment.  This value code must be passed to CWF and the PS&R. The amount shown in this value code must be paid to PIP providers on a claim -by-claim basis the same as outlier payments are paid to PIP providers.   160.1.2 - Remittance Advice Impact  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)   In order to  process this special add -on payment for new technologies, and report in the Remittance Advice (electronic and paper), contractors shall submit code ZL in the AMT segment of the Loop 2110 AMT01 of the ASC X12 835 Transaction. Contractors shall also submit code CS in the composite data element of the PLB segment in the 835 ASC X12 Transaction.  For PIP payment, the contractor includes only the add-on payment on a claim-by- claim basis.   The following reflects the remittance advice messages and associated codes that will appear when processing claims under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.   Group Code: OA CARC: 94  RARC: N/A  MSN: N/A  170 - Billing and Processing Instructions for Religious Nonmedical Health Care Institution (RNHCI) Claims  (Rev. 851, Issued:  02- 10-06; Effective/Implementation Dates:  05 -11-06)  170.1 - RNHCI Election Process  (Rev. 851, Issued:  02- 10-06; Effective/Implementation Dates:  05 -11-06)  See Chapter 5, Section 40 of Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual for a definition of RNHCI providers.  See Chapter 1, Section 130 of Pub. 100-02, Medicare Benefit Policy Manual for more information about the RNHCI benefit and coverage.   170.1.1 - Requirement for RNHCI Election  (Rev. 2930, Issued: 04- 11-14, Effective: 07-14-14, Implementation: 07-14-14)  The RNHCI benefit provides only for Part A inpatient services.  For an RNHCI to receive payment under the Medicare program, the beneficiary must make a written election to receive benefits under 1821 of the Act.  To elect religious nonmedical health care services, the beneficiary or the beneficiarys legal representative must attest that the individual is conscientiously opposed to acceptance of nonexcepted medical treatment, and the individuals acceptance of such treatment would be inconsistent with the individuals sincere religious beliefs.  All submissions regarding RNHCI services are processed by a single Medicare contractor as a specialty workload.  Currently, this specialty workload is part of Medicare Administrative Contractor Jurisdiction 10.  The completed election form must be filed with the contractor and a copy retained by the RNHCI provider.  See section 170.1.3 below for instructions on the submission of the election to the contractor.  The RNHCI provider should question each beneficiary prior to executing the election statement to determine if the beneficiary has Medicare Part B coverage in effect via a health plan or has recently received care (services or items, including physician- ordered durable medical equipment) for which Medicare payment was sought.  An affirmative answer will alert the RNHCI provider that subsequent claims under the election may be denied.  Occasionally, a Medicare beneficiary may seek services at a RNHCI that do not qualify for Medicare coverage and for which the beneficiary may seek payment from another insurer.  The beneficiary is not required to make an election of RNHCI benefits in this case.   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 .