(Medicare Claims Processing Manual)

Dollar Counts     7.     $ amount  of new checks returned during the reporting quarter  100,000    8.     $ amount of checks held during the reporting quarter  600,000    9.     $ amount reissued during the reporting quarter  500,000    10.   $ amount returned to trust fund during the reporting quarter  200,000        Report By:     ___Jane Doe______________________     Report Date:  __April 02, 2003___________________       80.6  Processing All Diagnosis Codes Reported on Claims Submitted to Carriers  (Rev.735, Issued: 10-31- 05, Effective: 04 -01-06, Implementation: 04-03-06) Carrier standard systems shall capture and process all diagnosis codes reported on a claim (both paper and electronic) up to the maximum permitted under the format.  The CWF shall process and maintain all diagnosis codes reported to CWF on a carrier processed claim.   90 - Patient Is a Member of a Medicare Advantage (MA) Organization for Only a Portion of the Billing Period  (Rev. 11731, Issued: 12-09-22, Effective: 01-11-23, Implementation: 01-11-23)  Where a patient either enrolls or disenrolls in an MA organization (See Pub. 100-01, the General Information, Eligibility, and Entitlement Manual, Chapter 5, 80 for definition) during a period of services, two factors determine whether the MA organization is liable for the payment.  Whether the provider is included in inpatient hospital or home health PPS, and  The date of enrollment. Hospital Services  If the provider is an inpatient acute care hospital, inpatient rehabilitation facility or a long term care hospital, and the patient changes MA status during an inpatient stay for an inpatient institution, the patients status at admission or start of care  determines liability.  If the hospital inpatient was not an MA enrollee upon admission but enrolls before discharge, the MA organization is not responsible for payment. For hospitals exempt from PPS (childrens hospitals, cancer hospitals, CAHs and Maryland waiver hospitals), if the MA organization has processing jurisdiction for the MA involved portion of the bill, it will direct the provider to split the bill and send t he appropriate portions to the appropriate FI or MA organization.  When forwarding a bill to an MA organization, the provider must also submit the necessary supporting documents. If the provider is not a PPS provider, the MA organization is responsible for payment for services on and after the day of enrollment up through the day that disenrollment is effective.  Home Health  If the patient was enrolled in the MA organization before start of care, the MA organization is liable until disenrollment. Upon disenrollment, an episode must be opened under home heath PPS for billing to the FI. If the beneficiary was not an MA enrollee upon admission but enrolls before discharge, the home health PPS episode will end as of the day before the MA enrollment.  The episode will be proportionately paid according to its shortened length (i.e., paid a pa rtial episode payment [PEP] adjustment).  The MA organization is responsible for payment as of the MA enrollment date.   91 - Moral and Religious Fee for Service Claims for Medicare Beneficiaries Enrolled in Certain Medicare Advantage (MA) Plans   100 - Medicare as a Secondary Payer  (Rev. 1, 10- 01-03) HO- 301, HO -469, CFR 411.32 The provider is required to determine whether Medicare is a primary or secondary payer for each inpatient admission of a Medicare beneficiary and outpatient encounter with a Medicare beneficiary.  Refer to the Medicare Secondary Payer Manual for specific MSP rules and for special admission and claims processing procedures for providers, suppliers, FIs, and carriers.  Medicare benefits are secondary to benefits payable by a third party payer, even if State law or the third party payer states that its benefits are secondary to Medicare benefits or otherwise limits its payments to Medicare beneficiaries.  Medicare will ma ke secondary payments except when the provider or supplier is either obligated to accept, or voluntarily accepts, as full payment, a third party payment that is less than its charges.  When a provider or supplier, or a beneficiary who is not physically or mentally incapacitated, receives a reduced third party payment because of failure to file a proper claim, the Medicare secondary payment may not exceed the amount that would have been payable if the third party payer had paid on the basis of a proper claim . The law mandates that Medicare is secondary payer for:   Claims involving Medicare beneficiaries age 65 or older who have GHP coverage based upon their own current employment status with an employer that has 20 or more employees, or that of their spouse of any age, or based upon coverage by a multiple employer, or multi- employer group health plan by virtue of their own, or a spouses, current employment status and the GHP covers at least one employer with 20 or more employees.  An individual has current employment status if the individual is actively working as a n employee, is the employer (including a self -employed person), or is associated with the employer in a business relationship; or is not actively working, but meets all of the following conditions:  o    Retains employment rights in the industry;  o    Has not had employment terminated by the employer, o    Is not receiving disability payments from an employer for more than six months;  o    Is not receiving social security disability benefits; and  o    Has group health plan (GHP) coverage based on employment that is not COBRA continuation coverage.  Examples of individuals who fall in the second group are teachers, employees who are on furlough or sick leave, and active union members between jobs.   Claims involving beneficiaries eligible for or entitled to Medicare on the basis of end stage renal disease (ESRD) during a period of 30 months) except where an aged or disabled beneficiary had GHP or LGHP coverage which was secondary to Medicare at the ti me ESRD occurred;  NOTE : The Balanced Budget Act of 1997 extended the ESRD coordination period to 30 months from 18 months for any individual whose coordination period began on or after March 1, 1996.  Individuals whose period began before that date have an 18- month coordination period.  This issue may need to be clarified with ESRD beneficiaries upon admission.  Claims involving automobile or non- automobile liability or no -fault insurance;   Claims involving government programs, e.g., Workers Compensation (WC), services authorized and paid for by the Department of Veterans Affairs (DVA), or Black Lung (BL) benefits; and  Claims involving Medicare beneficiaries under age 65 who are entitled to Medicare on the basis of disability and are covered by an LGHP (plans or employers, or employee organizations, with at least one participating employer that employs 100 or more employees) based upon the beneficiarys own current employment status or the current employment status of a family member.  110 - Provider Retention of Health Insurance Records  (Rev. 1, 10- 01-03) HO- 413, HH -480, SNF -545 The provider must maintain health insurance materials related to services rendered under title XVIII for the retention periods outlined below unless State law stipulates a longer period.  It must keep them available for reference by CMS, carrier, or FI, DHHS audit, or specially designated components for bill review, audit, and other refe rences.  110.1 - Categories of Health Insurance Records to Be Retained  (Rev. 1, 10- 01-03) HO- 413, HH -480, SNF -545.1 Providers retain records in all categories as applicable:  A.  Billing Material Provider copies of Form CMS -1450 and any other supporting documents, e.g., charge slips, daily patient census records, and other business and accounting records referring to specific claims.  B.  Cost Report Material  All data necessary to support the accuracy of the entries on the annual cost reports, including original invoices, cancelled checks, and provider copies of material used in preparing them.  Also include other similar cost reports, schedules, and related worksheets and contracts or records of dealings with outside sources of medical supplies and services or with related organizations. C.  Medical Record Material  For hospitals, utilization review committee reports and discharge summaries.  For hospitals and home health agencies, physicians certifications, and recertifications, and clinical and other medical records relating to health insurance claims.  D.  Provider Physician Materials  Provider physician agreements upon which Part A and Part B allocations are based.  After payment of the bill, the provider should not retain administrative and billing work records if the material does not represent critical detail in support of summaries related to these records.  These include punch cards, adding machine tapes, or othe r similar material not required for record retention. 110.2 - Microfilming Records  (Rev. 1, 10- 01-03) SNF -545.3, HO -413, HH -480 The provider may microfilm all health insurance records.  Billing material and related attachments that the provider furnished to the carrier or FI may be microfilmed providing the microfilm accurately reproduces all original documents. The provider must retain copies of all other categories of health insurance records in their original form.  If it microfilms them, it should store them in a low cost facility for the retention period described in 110.3. 110.3 - Retention Period  (Rev. 1, 10- 01-03) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The provider must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.  The provider (hospital, skilled nursing facility, and home health agency) must retain medical records in their original or legally reproduced form for a period of at least five years after it files with its FI the cost report to which the records apply, unless State law stipulates a longer period of time.  After payment of the bill, the provider need not retain administrative and billing work records provided that, and only to the extent that, such material does not represent critical detail in support of summaries related to the records outlined in 110.2.  These records include punch cards, adding machine tapes, internal controls, or other similar material not required for record retention. Providers must retain clinical records as follows:   The period of time required by State law;   Five years from the date of discharge when there is no requirement in State law; or  For a minor, three years after a resident reaches legal age under State law.  110.4 - Destruction of Records  (Rev. 1, 10- 01-03) HO- 413.1, HH -480.1, SNF -545.4  The provider may destroy material that no longer needs to be retained for title XVIII purposes, unless State law stipulates a longer period of retention.  To insure the confidentiality of the records, they must be destroyed by shredding, mutilation or other protective measures.  The method of final disposition of the records may provide for their sale as salvage.  The provider must report monies received as an adjustment to expense in the cost report for the year sold.  120 - Detection of Duplicate Claims  (Rev. 2678, Issued: 03- 29-13, Effective: 04 -29-13, Implementation: 04- 29-13)  120.1 - Overview  (Rev. 2678, Issued: 03- 29-13, Effective: 04 -29-13, Implementation: 04- 29-13)  The claims processing systems contain edits which identify exact duplicate claims and suspect duplicate claims.  All exact duplicate claims or claim lines are auto -denied or rejected (absent appropriate modifiers).  Suspect duplicate claims and claim lines are suspended and reviewed by the claims administration contractors to make a determination to pay or deny the claim or claim line.   Some claims that appear to be duplicates are actually claims or claim lines that contain an item or service, or multiple instances of an item or service, for which Medicare payment may be made.  Correct coding rules applicable to all billers of health care  claims encourage the appropriate use of condition codes or modifiers to identify claims that may appear to be duplicates, but, in fact, are not.  For example, there are some HCPCS modifiers that are appropriate to be appended to some services and can indicate that a claim line is not a duplicate of a previous line on the claim. Level I modifiers would typically be used by a biller to indicate that a  potential duplicate claim or claim line is not, in fact, a duplicate. Level II modifiers may also be used. The Level II modifiers RT and LT, for example, indicate that a service was performed on the right and left side of the body, respectively.  However, not every HCPCS code has an associated modifier to indicate that a claim line is not a duplicate.  In that case, the claims and claim lines are reviewed by Medicare contactors local software modules for a determination or they suspend for contrac tor review.   120.2 - Exact Duplicates  (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 continue to use the HICN as part of their processes.