(Medicare Claims Processing Manual)

POSITION   This subsection is directly after the page header.  It is fixed in size, full- page or 540 points in width and 25 points in height.     FORMATTING   [GR 2.1] black rule  [TB 2.2] date / provider continued [GR 3.4] dotted rule w/ space before  DYNAMIC RULES  Repeat header on subsequent pages as needed if the Claim Total Line subsection is not on the page.   PART A INPATIENT AND B OF A  SPECIFICATIONS   CONTENT   {Date of Service} / {Facility name} continued   HOSPICE, HOME HEALTH AND PART B (ASSIGNED AND UNASSIGNED) SPECIFICATIONS   CONTENT   {Date of Service} / {Provider name} continued   DME (ASSIGNED AND UN ASSIGNED) SPECIFICAT IONS   CONTENT   {Date of Service} / {Supplier name} continued    10.3.7 - Claims Calcu lations (Rev. 3210, Issued: 03- 03-15, Effective: 04- 16-15. Implementation: 04- 16-15)  This section provides calculations for correctly displaying dollar amounts in certain columns of the MSN.  NOTE THAT THE FOLLOWING SECTION HAS BEEN UPDATED TO REFLECT NEW  COLUMN NAMES, BUT HAS NOT OTHERWISE BEEN ALTERED FROM THE FORMER ITERATION OF CHAPTER 21.  SSMs ARE TO CONTINUE CURRENT PRACTICE FOR CALCULATIONS UNTIL ACCURATE REVISIONS COULD BE MADE AT A FUTURE DATE.    Part A -  Claim Approved? column is new; Is the Amount Medicare Paid column comparable to the old Deductible and Coinsurance column?  If not, it needs new instructions.  Date of Service now shows up at top of claim, not in its own column; first column now shows Benefit Period date.   Part B -  Service Approved? column is new; Date of Service now shows up at top of claim, not in its own column   Unassigned Part B - Service Approved? column is new; Date of Service now shows at top of claim, not in its own column.    B of A - Service Approved? column i s new; Are the Medicare- Approved Amount and Amount Medicare Paid columns comparable to the old Non-Covered Charges and Deductible and Coinsurance columns?  If not, these need instructions.  Date of Service now shows up at top of claim, not in its own column.   DME -  Item/Service Approved? column is new; Date of Service now shows up at top of claim, not in its own column.  A. Part A Calculations   Maximum You May Be Billed Column   The following chart is to be used to display the Maximum You May Be  Billed amounts for each service line on outpatient claims other than those that have a Medicare secondary payment less than the amount Medicare would have paid if it were primary.  See the Medicare Secondary Payer Manual, Chapter 5, if the Medicare secon dary payment is less than the amount Medicare would pay if it were primary.   Calculations for Completing Maximum You May Be Billed Column - Outpatient Claims  Instructions/Source of Dollar Amount for Calculations  A.  Service line billed amount  This is the service line billed amount.  This amount should be shown in the Amount Provider Charged column of the MSN.  B.  Psychiatric reduction  B = A x .375 This is applicable only to services subject to the outpatient psychiatric limitation.  For all other se rvices, B = 0.  C.  Amount remaining after psychiatric reduction  C = A - B. D.  Deductible applied  This is the amount of deductible applied on the service line.  If no deductible applied, D = 0.  E.  Amount charged less deductible  E = C - D. F.  Less Medicare copayment amount  Depending upon the service, F may equal any of:  1.  E - where services are paid at 100% of the approved amount;   2.  80% of E - where coinsurance is based on approved amount;   3.  E minus 20% of E - where coinsurance is based on charges; or   4.  OPPs payment amount minus the fixed beneficiary copayment where hospital outpatient PPS is involved.  G.  Amount after deductible, copayment and psychiatric reduction  G = E - F. H.  Of the billed amount  This is dollar amount shown in A.  I.  Less what Medicare owes  This is the dollar amount shown in G.  J.  Net responsibility  J = H - I. K.  Plus charges that Medicare does not cover  This step represents charges that Medicare does not cover shown in the Non -Covered Charges column on the MSN.  Charges for which the beneficiary is determined to have no liability should be excluded from this step.  Exclude dollar amounts for denials 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;   Calculations for Completing Maximum You May Be Billed Column - Outpatient Claims  Instructions/Source of Dollar Amount for Calculations   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 outpatient claims.  Claims submitted with a beneficiary paid amount require the additional calculations shown in Subsection C below.   Display of the Maximum You May Be Billed Column for MSP Claims  If the Medicare secondary payment plus the amount the primary insured paid equals or exceeds what Medicare would have paid, the Maximum You May Be Billed column for each approved service should display $0.00.   If the prima ry insurer paid amount is less than what Medicare would have paid, the amount shown in Maximum You May Be Billed column for each service line needs to be reduced using the following formula.   For the first service line, the amount Maximum You May Be Bil led = Deductible + Coinsurance -  Primary Paid Amount + Non- Covered Charges.   For the second service line, the same formula would be followed with the Primary Amount equaling the Primary Paid minus the Deductible + Coinsurance from the first line.  Continue in this manner until the primary paid amount equals either $0.00 or the Deductible + Coinsurance equals $0.00.   Display of the Maximum You May Be Billed Column for Claims Submitted with a Beneficiary Paid Amount:   If a claim is submitted with a benefic iary 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 to 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 shown for the Maximum You May Be Billed column, subtract the amount the beneficiary paid from that amount, and display the difference in the Maximum You May Be Billed column for that service line.  Step 2: If the amount the beneficiary paid is greater than 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.   Repeat these steps with any remaining beneficiary paid amounts.  If a balance remains after all services lines have been considered, that amount should match the check amount to the beneficiary on that claim.  If payment was made to the beneficiary, the balance should be shown in the appropriate blank of message 34.4.  If a check was not issued, print messa ge 34.2.   B. Part B Calculations   Medicare Paid You/Provider Column -  Assigned and Unassigned Claims   The following chart is to be used to display the Medicare paid amount for each service line on assigned and unassigned claims other than those that have a Medicare secondary payment less than the amount Medicare would have paid if it were primary.  Steps for Displaying Medicare Paid Amounts on the Service Line  Instructions/Source of Dollar Amounts  A. Service line approved am ount This is the approved amount for the service.  Do not include interest amounts paid or applied to the service line.   B. Mental Health Treatment Limitation  B = A x 37.5 This is applicable only for services subject to the outpatient mental health treat ment limitation.  For all other services, B = 0.  C. Amount remaining after mental health treatment limitation  C = A - B. D. Deductible applied  This is the amount of deductible applied on the service line.  If no deductible applied, D = 0.  Steps for Displaying Medicare Paid Amounts on the Service Line  Instructions/Source of Dollar Amounts  E. Approved amount less deductible  E = C - D. F. Less Medicare copayment  F = E x .20 Services paid at 100% of the approved amount do not have a copayment .  For services paid at 100%, F = 0.  G. Amount after deductible, copayment and mental health treatm ent limitation  G = E - F. H. Less 10% for late filing  H = G x .10 If service line is part of an unassigned claim or there is no reduction for late filing, H = 0.  I. Payment after reduction  I = G - H. J. Less Balanced Budget Law Reduction  The total Balanced Budget Law reductions applied to the service line.  If no reduction, J = 0.  K. Payment after reduction  K = I - J. L. Medicare paid amount  L = K - Display this amount in the Medicare Paid You/Provider column.   MAXIMUM You May Be Billed Column -  Assigned Claims  The following chart is to be used to display the Maximum You May Be Billed amounts for each service line on assigned 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 - Assigned Claims  Instructions/Source of Dollar Amount for Calculations  A. Service line approved amount  This is the service line approved amount.  This amount should be shown in the Medicare Approved column of the MSN.   B. Mental Health Treatment Limitation  B = A x 37.5 This is applicable only to services subject to the outpatient psychiatric limitation.   For all other services, B = 0.   C. Amount remaining after mental health treatment limitation  C = A - B. D. Deductible applied  This is the amount of deductible applied on the service line.  If no deductible applied, D = 0.   E. Approved amount less de ductible  E = C - D. F. Less Medicare copayment amount  F = E x .20 Services paid at 100% of the approved amount do not have a copayment .  For services paid at 100%, F = 0.   Calculations for Completing Maximum You May Be Billed Column - Assigned Claims  Instructions/Source of Dollar Amount for Calculations  G. Amount after deductible, copayment and mental health treatment limitation  G = E - F. H. Of the approved amount  This is dollar amount shown in A.  I. Less what Medicare owes  This is the dollar amount shown in G.  J. Net responsibility  J = H - I. K. Plus charges that Medicare does not cover  This step represents charges that Me dicare does not cover and the beneficiary is liable.  Charges for which the beneficiary is determined to have no liability should be excluded from this step.  Exclude 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 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