(Medicare Claims Processing Manual)

30.13 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.14 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.15 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.16 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.17 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.18 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.19 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.19.1 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.19.2 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.19.3 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.19.4 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.20 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  30.21 - Requesting Assistance in Resolving Problem Areas in the Inquiry/Inquiry Response Procedures  (Rev. 1, 10- 01-03) A3-3523, 3- 6008   See 70.  30.21.1 - HMO -Related Master File Corrections  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  The A/B MAC (A), (B), or (HHH), or DME MAC will fully document and send to the HMO inquiries concerning problems with HMO data on the HI Master.  The HMO will resolve the problem and advise the contractor of the results.   30.22 - Provider Problems Obtaining Entitlement Information  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  If after application of the above procedures, the provider encounters significant problems in obtaining information regarding Medicare entitlement or benefits in order to accurately prepare bills, the provider should contact the A/B MAC (A), (B), or (HHH), or DME MAC for assistance.  However, these requests should be on a non- routine basis.  The MAC will assist providers in obtaining entitlement information.  The MAC may temporarily refuse assistance if a pattern of abuse is discovered.  Situations that may require MAC assistance are:    When the patient dies following admission.  It may be necessary to file timely with an estate;    When the patient is not in a physical or mental condition to discuss his/her entitlement, and no other person with knowledge of the patients affairs is available;    When the provider has reason to believe the beneficiary may need lifetime reserve days, and his/her signature must be obtained if the available lifetime reserve days are not to be used for this admission and other financial arrangements must be made;    When it is suspected that the beneficiary may have exhausted his/her Medicare benefits, and timely confirmation is needed in order to file for possible supplemental benefits; and    When the patient has experienced repeated admissions during the same spell of illness, and determining available benefits for the beneficiary is difficult.   50 - Critical Case Procedures - Establishing Entitlement Under Part A and B  (Rev. 1, 10- 01-03)  See Chapter 27.   60 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  60.1 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  60.2 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16).  70 - SSO Assistance in Resolving Entitlement Status Problems (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 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.   A. Social Security Office (SSO) Assistance   The A/B MAC (A), (B), or (HHH), or DME MAC directs initial requests for assistance to the SSO if the problem is caused by difficulties in determining the beneficiarys correct entitlement status.  Examples of situations that may require SSO assistance are:    Problems involving Railroad Retirement Board (RRB) jurisdiction;    Evidence that a beneficiary has utilization under more than one Medicare beneficiary identifier but there is no awareness of any cross -reference action taken by CMS; or    The beneficiarys name, address, sex code, date of birth, or date of death is incorrect on the HI master record.   In the event the SSO is unable to resolve the entitlement problem (e.g., cross referencing of HI records), the MAC requests assistance from the RO.   90 - Outpatient Hospital Registration Procedures  (Rev. 1, 10- 01-03) HO- 350  90.1 - Patient Identification  (Rev. 4247, Issued: 03- 01-19, Effective: 04 -01-19, Implementation: 04- 01 -19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's 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.   Upon registration of a Medicare beneficiary, or as soon thereafter as practical, the hospital will ask the patient for his/her health insurance card to obtain the Medicare beneficiary identifier.  If the patient is unable to provide it, the hospital will c ontact the SSO for assistance.   90.2 - Determining Whom to Bill  (Rev. 1, 10- 01-03) HO- 350.B   The procedures for determining whether another payer exists are the same for outpatient situations as for inpatient.  Therefore, the hospital will follow 20 for developing other coverage.   90.3 - Source of Admission - Outpatient Hospital  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  The hospitals registration process must distinguish whether the referral source for this registration/admission is from:   Its own inpatient hospital;    An encounter in another hospital (see 90.6 for definition of encounter); or    Any other source -  See chapter 25.   Hospitals must determine the appropriate source of admission from internal records or by asking the patient who referred him/her, and whether the referral took place as a result of an encounter in the servicing hospital, another hospital, or elsewhere.   The following coding must be used on the outpatient claim.  Therefore admission/registration processes must obtain the information.  1. Physician Referral -  The patient was referred to this facility for outpatient or referenced diagnostic services by his/her personal physician, or the patient independently requested outpatient services (self -referral).   2. Clinic Referral -  The patient was referred to this facility for outpatient or referenced diagnostic services by this facilitys clinic or other outpatient department physician.  3. HMO Referral -  The patient was referred to this facility for outpatient or referenced diagnostic services by an HMO physician.  4. Transfer from a Hospital -  The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another acute care facility.   5. Transfer from a SNF -  The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of the SNF where the patient is an inpatient.   6. Transfer from Another Health Care Facility -  The patient was referred to this facility for outpatient or referenced diagnostic services by a physician of another health care facility where the patient is an inpatient.  7. Emergency Room -  The patient was referred to this facility for outpatient or referenced diagnostic services by this facilitys emergency room physician.  8. Court/Law Enforcement -The patient was referred to this facility for outpatient or referenced diagnostic services upon the direction of a court of law, or upon the request of a law enforcement agency representative.   9. Information not available.  10. Transfer from a CAH -  The patient was referred to this facility for outpatient or referenced diagnostic services by (a physician of) the CAH were the patient is an inpatient.   The hospital must determine the proper source of admission code based on the patients response and/or any other information the hospital may have available from its preregistration records or scheduling data.  The hospital must enter the proper source of admission code on the claim.  NOTE:  Information regarding the form locator number that corresponds to the source of admission code and a table to crosswalk its CMS -1450 form locator to the 837 transaction is found in Chapter 25.   If the patient was referred for services by a physician at:    This hospital, the hospital enters codes 2 or 7;    Another hospital, the hospital enters code 4; or    Some other source, the hospital enters codes 1, 3, 5, 6, 8, 9, or A, as appropriate.