(Medicare Claims Processing Manual)

The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The provider submits late charges on bills to the FI as bill type xx5.  These bills contain only additional charges.  However, if the late charge is for:   Services on the same day as outpatient surgery subject to the ASC limit;  Services on the same day as services subject to OPPS;   ESRD services paid under the composite rate;   Inpatient accommodation charges;   Services paid under HH PPS; and   Inpatient hospital or SNF PPS ancillaries.  It must be submitted as an adjustment request.  The provider may submit the following charges omitted from the original paid bill to the FI as late charges:   Any outpatient services other than the exceptions stated in this paragraph.  This includes late charges for non- HH PPS services under Part B, hospice services other than the services of hospice -employed attending physicians, hospital outpatient services except those on the day of ambulatory surgery subject to the ASC payment limitation or the day of outpatient services subject to OPPS, RHC services, OPT services, SNF outpatient services, CORF services, FQHC services, CMHC serv ices, ESRD services not included in the composite rate; and   Any inpatient SNF ancillaries or inpatient hospital ancillaries other than from PPS providers.  The provider may not submit late charges (xx5) for inpatient hospital or SNF accommodations.  The provider must submit these as adjustments (bill type xx7).  The FI has the capability to accept xx5 bill types electronically and process them as initial bills except as described in the following paragraph.  The FI also performs the following edit routines on any xx5 type bills received:   Pass all initial bill edits, including duplicate checks.   Must not be for any of: Inpatient hospital or SNF PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, services on the same day as services subject to OPPS, or ESRD services included in the composite rate.  These are rejected back to the hospital with the message,  This change requires an xx7 debit -only or xx8 cancel -only request from you.  Late charges are not acceptable for inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, services on the same day as services subject to OPPS, or ESRD services included in the composite rate.   When an xx5 suspends as a duplicate, (dates of service equal or overlapping, provider ID equal, Medicare beneficiary identifier equal, and patient surname equal), the FI must determine the status of the original paid bill.  If it is denied, the FI must deny the late charge bill.   If an xx5 does not suspend as a potential duplicate, the FI rejects it back to the provider with the message, No original bill paid.  Please combine and submit a single original bill (xx1).   If the original bill was approved and paid, the FI compares the revenue codes on the original paid bill with the associated late charge bill:  For all providers (any bill type), if any are the same, and are revenue codes 41x, 42x, 43x, 44x, 63x, 76x, or 91x, the FI rejects the bill back to the provider with the message,  You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.   For HHA services not under a plan of care (bill type 34x), the FI must apply the same logic for the following additional revenue codes.  If any are the same and are revenue codes 27x, 29x, 55x, 56x, 57x, 58x, 59x, 60x, or 63x, the FI rejects the bill back to the provider with the message,  You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.   For hospital outpatient services (bill type 13x only), the FI must apply the same logic for the following additional revenue codes.  If any are the same and are revenue codes 255, 32x, 33x, 34x, 35x, 40x, 62x, 73x, 74x, 92x, or 943, the FI rejects the bill  back to the hospital with the message,  You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.   For RDFs (bill type 72x or 73x), the FI must apply the same logic for the following additional revenue codes; if any are the same and are revenue codes 634, 635, 82x, 83x, 84x, 85x, or 88x, the FI rejects the bill back to the provider with the message, You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.   If the late charges bill relates to two or more original paid bills, and one of these is denied, the FI must suspend and investigate the late charge bill.  The FI must compare total charges on the original paid bill with those on the associated late charge bill, and suspend and investigate any xx5 bill type with total charges in excess of those on the original paid bill.  This edit suggests the provider may have rebilled the already paid services.  The FI may decide to perform additional edits on late charge bills.  130.2 - Inpatient Part A Hospital Adjustment Bills  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will co ntinue to use the HICN as part of their processes.   For adjustment requests reported as a claim record, the hospital must report the ICN/DCN of the original bill.  See the ASC X12 Institutional Claim Implementation Guide for instructions for the electronic format and Chapter 25 for instructions for Form CMS -1450.  Where payment is handled through the cost reporting and settlement processes, the hospital accumulates a log for those items not requiring an adjustment request.  For cost settlement, the A/B MAC (A) pays on the basis of the log.  This log must inc lude:    Patient name;   Medicare beneficiary identifier;   Dates of admission and discharge, or from and thru dates;   Adjustment in charges (broken out by ancillary or routine service); and   Any unique numbering or filing code necessary for the hospital to associate the adjustment charge with the original billing.   NOTE : Hospitals in Maryland, which are not paid under PPS or cost reports, submit an adjustment request for inpatient care of $500 or more, and keep a log as described above for lesser amounts.  Because there are no adjustment requests, the A/B MAC (A) enters the payment amounts from the summary log into the PPS waiver simulation and annually pays the items on the log after the cost report is filed.  After cost reports are filed, the A/B MAC (A) makes a lump sum payment to cover these charges as shown on the summary log.  The hospital uses the summary log for late charges only under cost settlement (outpatient hospital), except in Maryland.  Maryland and cost hospitals are required to meet the 12- month timeframe for timely filing of claims, including late charges.   For all adjustments other than QIO adjustments (e.g., provider submitted adjustments and/or those the A/B MAC (A) initiates), the A/B MAC (A) submits an adjustment request to CWF following its acceptance of the initial bill.  To verify CMSs acceptance, the A/B MAC (A) can submit a status query.   Under inpatient hospital prospective payment, adjustment requests are required from the hospital where errors occur in diagnosis and procedure coding that changes the DRG, or where the deductible or utilization is affected.  A hospital is allowed 60 days f rom the date of the A/B MAC (A) payment notice (remittance advice) for adjustment requests where diagnostic or procedure coding was in error resulting in a change to a higher weighted DRG.  Adjustments reported by the QIO have no corresponding time limit and are adjusted automatically by the A/B MAC (A) without requiring the hospital to submit an adjustment request.  However, if diagnostic and procedure coding errors have no effect on the DRG, adjustment requests are not required.  Under PPS, for long- stay cases, hospitals may bill 60 days after an admission and every 60 days thereafter if they choose.  The A/B MAC (A) processes the initial bill through Grouper and PRICER.  When the adjustment request is received, it processes it as an adjustment.  In this case, the 60- day requirement for correction does not apply.  130.2.1 - Tolerance Guidelines for Submitting Inpatient Part A Hospital Adjustment Requests  (Rev. 1, 10- 01-03) A3-3664.1.A  When a bill is submitted and the hospital or the FI discovers an error, the hospital submits an adjustment request using the CMS -1450, if the error is a change in the:   Number of inpatient days (including a change in the length of stay, or a different allocation of covered/noncovered days);   Blood deductible;   Inpatient cash deductible of more than $1;   Servicing hospital;  For inpatient hospital bills paid under PPS, CMS also requires an adjustment request for a change in:   Discharge status in a PPS hospital;   The DRG code; or   Outlier payment amount.  The hospital submits most adjustment requests as debits, using bill type xx7. Also, it submits a debit- only adjustment request to the FI if it previously submitted an interim bill for a PPS hospital stay or wishes to change the number of days in any inpatient stay.  The FI then submits the adjustment to CWF.  An adjustment from the QIO for any of the above also requires a submission to CMS via CWF.  If an adjustment the hospital initiates results in a change to a higher weighted DRG, the FI edits the adjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to be adjusted.  If it is, the FI processes the claim for payment.  If the remittance date is more than 60 days prior to the receipt date of the adjustment request and results in a change to a lower weighted DRG, the FI processes the claim for payment and forwards it to CWF.   130.3 - SNF Part A Adjustments  (Rev. 1, 10- 01-03)   130.3.1 - Tolerance Guides for Submitting SNF Inpatient Adjustment Requests  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medic are card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   SNF inpatient adjustment requests adhere to the same billing instructions as non- inpatient adjustment requests with the following changes.  When an initial bill has been submitted and the provider or FI discovers an error on the bill, an adjustment request  is submitted if the change involves one of the following:    A change in the Part B cash deductible of more than $1.00  A change in the number of inpatient days;   A change in the blood deductible;   A change in provider number;   A change in coinsurance which involves an amount greater than $1.99;   A change in the HIPPS code to correct a data input error or,   Effective for changes for services June 1, 2000, change in HIPPS code due to an MDS correction.  (Such adjustments are required within 120 days of the through date on the initial bill.) NOTE:  See Chapter 6, Section 35 for information on submitting adjustments to HIPPS codes resulting from MDS corrections.  Late charge billings (type of bill xx5) are not acceptable for SNF PPS Part A services.  The reason for an adjustment (Claim Change Reasons) is reported in one of the condition code fields.  Claim Change Reason Codes applicable to SNFs are: