(Medicare Claims Processing Manual)

10.11 - Retroactive Entitlement  (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)  When an application for social security benefits is filed by a person 65 years of age or older, the person may inform the SSO that he/she received hospital services in the retroactive period of up to six months for which he/she may be entitled to benefits.  In these cases, the provider may bill for covered retroactive services but must verify the patients eligibility through the A/B MAC (A), (B), or (HHH), or DME MAC before billing.  If the patient paid, the provider must refund the appropriate amount to the patient.   10.12 - SNF Verification of Prior Hospital Stay and Transfer Requirements  (Rev. 1, 10- 01-03) SNF -414  SNFs must verify that the beneficiary was discharged from a hospital with a transfer agreement with the SNF and that:   a. The date of discharge is on or after the first day of the month in which the beneficiary became entitled to Medicare;   b. The hospital stay was at least three calendar days in duration (hospital days to which waiver of liability was applied cannot be used to satisfy the 3- day requirement); and   c. The 3 -day qualifying stay was within 30 days of the SNF admission, unless the rules for exception apply.   The hospital usually sends the SNF a patient transfer form or other record in accordance with the transfer agreement.  The dates of the hospital stay are required on the claim.   For more information on the above criteria, see Chapter 8 of the Medicare Benefit Policy Manual.   20 - Obtaining Information to Determine Whether to Bill Medicare or Another Payer  (Rev. 1, 10- 01-03) HO- 300, SNF -401  The provider must ascertain whether the patient is a member of a Medicare + Choice organization (M+CO).  If the patient is a member of an M+CO, the provider must contact the M+CO specified by the patient or identified on the patients membership card, so the provider may determine whether to submit the claim to the M+CO.  If the patient indicates that he/she is not a member of an M+CO, the provider, in order to determine whom to bill, develops for situations where Medicare is the secondary payer by obtaining answers to the Admission Questions to Ask Medicare Beneficiaries  contained in Chapter 3 of the Medicare Secondary Payer Manual.  If another insurer is identified as primary to Medicare, the provider follows the procedures in the Medicare Secondary Payer (MSP) Manual.   20.1 - Provider Development of Medicare Secondary Payer  (Rev. 1, 10- 01-03) HO- 301, SNF -401, A -03-031  Medicare is the secondary payer under certain circumstances.  See Medicare Secondary Payer (MSP) Manual, Chapter 1, for related instructions.  30 - Provider/Supplier Obtaining/Verifying the Medicare beneficiary identifier  and Entitlement Status  (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.   It is important that the patients Medicare beneficiary identifier be obtained and accurately recorded because the claim cannot be processed if the Medicare beneficiary identifier is missing or incorrect. A social security number is not sufficient.   When a patient 65 years of age or over, or a younger patient who possibly has entitlement to Medicare as a disability beneficiary or under the provisions for coverage of persons needing a kidney transplantation or dialysis, is admitted or registered for se rvices, the provider asks for the health insurance card, Temporary Notice of Medicare Eligibility, or other notice the patient has received from CMS or an A/B MAC (A), (B), (HHH), or DME MAC which shows the Medicare beneficiary identifier.  If a patient or  prospective patient is within three months of age 65, or is disabled or has ESRD, and has not applied for HI entitlement, the provider advises the patient to contact the SSO, or to have someone do so on the patients behalf.  The provider may arrange with the SSO to routinely bring such cases to the SSOs attention.  This requirement also applies to inpatient services for which no payment is due because providers are required to submit inpatient claims even when benefits are exhausted or are not payable for some reason.  The CMS requires this data to record necessary benefit information on CMS records.  Where the patient refuses to request payment and refuses to furnish information about his/her Medicare beneficiary identifier, the provider documents the records accordingly and attempts to get the Medicare beneficiary i dentifier from the SSO.   30.1 - Cross-Reference of Medicare Beneficiary Identifier                      (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.   If a beneficiarys entitlement to Medicare has been transferred from one Medicare beneficiary identifier to another, the CWF will cross -reference the old number to the new number.  If there has been utilization of benefits under each number, all data will be combined under the new number.  A. Disposition Code 51   1. If, after submitting the admission notice or Part B claim to CMS, the MAC receives a disposition code of 51 with trailer code 01 containing a possible Medicare beneficiary identifier, the MAC investigates the new Medicare beneficiary identifier, and if it believes the new Medicare beneficiary identifier is correct, the MAC resubmits the claim under the new Medicare beneficiary identifier.  CWF responds with an appropriate disposition code and any associated trailers for processing the claim.   2. If the MAC receives a disposition code of 51 without trailer code 01, or after investigation determines the Medicare beneficiary identifier in the 01 trailer is incorrect, it denies the claim using the following message:   Payment cannot be made for the services you received from (name of provider) because we have no record of your Medicare beneficiary identifier.  Please write your correct number on the claim and resubmit the claim to (name of provider).  If you think the n umber is right, check with your local Social Security Office.   B. Disposition Code 55   If CWF returns disposition code 55 and trailer code 08 containing an error code of 5052, indicating a mismatch in the beneficiarys personal characteristics, CWF will also return to the MAC what it believes to be the proper information on trailer code 10.  The header portion of the response also contains the corrected sex and birth date, if applicable, of the beneficiary.   The MAC investigates the information provided, corrects the information on the claim, and resubmits it to CWF.  If the MAC continues to receive a code 55, it contacts the Host through locally established procedures.  See Chapter 27.  30.2 - Health Insurance (HI) Card  (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.   As part of health insurance electronic data processing, HI cards are issued by CMS (or by the RRB where railroad retirement beneficiaries are involved) to individuals who have established entitlement to health insurance.  (See Chapter 2 of the Medicare Gen eral Information, Eligibility, and Entitlement Manual.)  The health insurance card is used to identify the individual as being entitled and serves as a source of information required to process Medicare claims or bills.  The health insurance card displays the beneficiarys name, sex, Medicare beneficiary identifier, and effective date of entitlement to hospital insurance and/or medical insurance.   If any MAC receives an inquiry about replacing a lost or destroyed HI card, it informs the inquirer to get in touch with the SSO nearest the inquirers address for assistance.  SSO addresses are generally listed in local telephone directories under Social  Security Administration.   A health insurance card is acceptable without a signature, but the provider will ask the patient to sign it.   30.3 - Temporary Eligibility Notice  (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.   The SSO may issue a temporary health insurance eligibility notice, pending the issuance of a health insurance card, when the beneficiary is in need of immediate medical services.  The provider may obtain the patients name and Medicare beneficiary identifi er from the temporary eligibility notice.  See Chapter 2 of the Medicare General Information, Eligibility, and Entitlement Manual for an example of the temporary notice.  For claims processed by the A/B MAC (B) or DME MAC, the individual, the individuals physician, or other supplier must show the Medicare beneficiary identifier on the request for Medicare payment and on other related bills and documents.  Because Health In surance records are maintained by the individuals Medicare beneficiary identifier, the Medicare beneficiary identifier must be used on all communications. claim number, the claim number must be used on all communications.   30.4 - Certificate of Social Insurance Award  (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.   Health insurance beneficiaries receive a Certificate of Social Insurance Award, SSA -30, showing the Medicare beneficiary identifier, dates of entitlement to Part A and/or Part B benefits, and the following statement:   This notice may be used if Medicare services are needed before you receive your health insurance card.  30.5 - Medicare Summary Notice (MSN)  (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 co ntinue to use the HICN as part of their processes.   If patients cannot furnish their health insurance cards when admitted, they may have a MSN form showing the Medicare beneficiary identifier.  A notice is mailed to a beneficiary shortly after Part A or Part B benefits have been paid on the beneficiarys behalf.  Deductible status is also shown on these forms.  30.6 - Provider Access to CMS and A/B MAC (A) or (HHH)  Eligibility Data (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.