(Medicare Claims Processing Manual)

30.2.12 - Establishing That a Person or Entity Qualifies to Receive Payment on Basis of Reassignment - for Carrier Processed Claims  30.2.13 - Billing Procedures for Entities Qualified to Receive Payment on Basis of Reassignment - for A/B MAC Part B Processed Claims  30.2.14 - Correcting Unacceptable Payment Arrangements  30.2.14.1 - Questionable Payment Arrangements  30.2.15 - Sanctions for Prohibited Payment Arrangement  30.2.16 - Prohibition of Assignments by Beneficiaries  30.3 - Physician/Practitioner/Supplier Participation Agreement and Assignment - Carrier Claims  30.3.1 - Mandatory Assignment on Carrier Claims  30.3.1.1 - Processing Claims for Services of Participating Physicians or Suppliers  30.3.2 - Nature and Effect of Assignment on Carrier Claims  30.3.3 - Physicians Right to Collect From Enrollee on Assigned Claim Submitted to Carriers  30.3.4 - Effect of Assignment Upon Rental or Purchase of Durable Medical Equipment on Claims Submitted to Carriers  30.3.5 - Effect of Assignment Upon Purchase of Cataract Glasses From Participating Physician or Supplier on Claims Submitted to Carriers  30.3.6 - Mandatory Assignment Requirement for Physician Office Laboratories on Claims Submitted to Carriers  30.3.7 -  Billing for Diagnostic Tests (Other Than Clinical Diagnostic Laboratory Tests) Subject to the Anti -Markup Payment Limitation -  Claims Submitted to A/B MACs (B)  30.3.8 -  Mandatory Assignment and Other Requirements for Home Dialysis Supplies and Equipment Paid Under Method II on Claims Submitted to Carriers  30.3.9 -  Filing Claims to a Carrier for Nonassigned Services  30.3.10 -  Carrier Submitted Bills by Beneficiary  30.3.11 -  Carrier Receipted Bill -  Definition  30.3.12 -  Carrier Annual Participation Program  30.3.12.1 -  Annual Open Participation Enrollment Process  30.3.12.1.2 -  Annual Medicare Physician Fee Schedule File Information  30.3.12.2 -  Carrier/MACs Participation Agreement 30.3.12.3 -  Carrier Rules for Limiting Charge  30.3.13 -  Charges for Missed Appointments  40 - Termination of Provider Agreement  40.1 -  Voluntary Termination 40.1.1 -  Close of Business  40.1.2 -  Change of Ownership 40.1.3 -  Expiration and Renewal -Nonrenewal of SNF Term Agreements  40.2 -  Involuntary Terminations  40.2.1 -  Processing Involuntary Terminations  40.2.2 -  FI Report on Provider Deficiencies  40.2.2.1 -  Subsequent Communications With Provider  40.3 -  Readmission to Medicare Program After Involuntary Termination  40.3.1 -  Effective Date of Provider Agreement  40.3.2 -  Fiscal Considerations in Provider Readmission to Medicare Program After Involuntary Termination 40.4 -  Payment for Services Furnished After Termination, Expiration, or Cancellation of Provider Agreement  40.4.1 -  Reviewing Inpatient Bills for Services After Suspension, Termination, Expiration, or Cancellation of Provider Agreement, or After a SNF is Denied Payment for New Admissions  40.4.2 -  Status of Hospital or SNF After Termination, Expiration, or Cancellation of Its Agreement  40.5 -  FI/Carrier/DMERC Responsibilities for Informing Providers of Changes  50 - Filing a Request for Payment With the Carrier or FI  50.1 -  Request for Payment From the Carrier or FI  50.1.1 -  Billing Form as Request for Payment  50.1.2 -  Beneficiary Request for Payment on Provider Record - ASC X12 837 Institutional Claim Format and Form CMS -1450 50.1.3 -  Signature on the Request for Payment by Someone Other Than the Patient  50.1.4 -  Request for Payment as a Claim for HI Entitlement 50.1.5 -  Refusal by Patient to Request Payment Under the Program  50.1.6 -  When Beneficiary Statement is Not Required for Physician/Supplier Claim  50.1.7 -  Definition of a Claim for Payment 50.1.8 -  Establishing Date of Filing -  Postmark Date -  Carriers  50.2 -  Frequency of Billing for Providers  50.2.1 -  Inpatient Billing From Hospitals and SNFs  50.2.2 -  Frequency of Billing for Providers Submitting Institutional Claims  With Outpatient Services  50.2.3 -  Submitting Bills In Sequence for a Continuous Inpatient Stay or Course of Treatment  50.2.4 -  Reprocess Inpatient or Hospice Claims in Sequence  50.3 -  When an Inpatient Admission May Be Changed to Outpatient Status  50.3.1 -  Background  50.3.2 -  Policy and Billing Instructions for Condition Code 44 60  Provider Billing of Non- covered Charges on Institutional Claims  60.1 -  General Information on Non- covered Charges on Institutional Claims  60.1.1 -  Basic Payment Liability Conditions  60.1.2 -  Billing Services Excluded by Statute  60.1.3 -  Claims with Condition Code 21  60.1.3.1  Provider -liable Fully Noncovered Outpatient Claims  60.2 -  Noncovered Charges on Inpatient Bills  60.2.1  Billing for Noncovered Procedures in an Inpatient Stay 60.3 -  Noncovered Charges on Institutional Demand Bills  60.3.1 -  Background on Institutional Demand Bills (Condition Code 20)  60.3.2 -  Inpatient and Outpatient Demand Billing Instructions  60.4 -  Noncovered Charges on Outpatient Bills  60.4.1 -  Outpatient Billing With an ABN (Occurrence Code 32)  60.4.2 -   Line -Item Modifiers Related to Reporting of Non- covered Charges When Covered and Non- covered Services Are on the Same Outpatient Claim 60.4.3  Liability Considerations for Bundled Services  60.5 -  Coding That Results from Processing Noncovered Charges  70 - Time Limitations for Filing Part A and Part B Claims  70.1 -  Determining Start Date of Timely Filing Period --Date of Service  70.2 -  Definition of a Claim for Payment 70.2.1 -  Appropriate Medicare Contractor  70.2.2 -  Form Prescribed by CMS  70.2.3 -  In Accordance with CMS Instructions  70.2.3.1 -  Incomplete or Invalid Submissions  70.2.3.2 -  Handling Incomplete or Invalid Submissions  70.3 -  Determining End Date of Timely Filing Period Receipt Date  70.4 -  Determination of Untimely Filing and Resulting Actions  70.5 -  Application to Special Claim Types  70.6 -  Filing Claim Where General Time Limit Has Expired  70.7 -  Exceptions Allowing Extension of Time Limit  70.7.1 -  Administrative Error  70.7.2  Retroactive Medicare Entitlement  70.7.3  Retroactive Medicare Entitlement Involving State Medicaid Agencies  70.7.4 -  Retroactive Disenrollment from a Medicare Advantage Plan or Program of All -Inclusive Care for the Elderly (PACE) Provider Organization  70.8 -  Filing Request for Payment to Carriers Medicare Part B  70.8.1 -  Splitting Claims for Processing  70.8.2 -  Replicating Claims for Processing  70.8.3 -  Methods of Claiming Benefits for Services by Physicians and Suppliers  70.8.4 -  Claims Forms  CMS -1490S and CMS -1500 70.8.5 -  Photocopies  70.8.6 -  Penalty for Filing Claims after One Year  70.8.8 -  Penalty for Filing Claims after One Year  70.8.8.6  Monitoring Claims Submission Violations  70.8.8.7  Notification Letters  70.8.8.8  Violations That Are Not Developed For Referral  80 - Carrier and FI Claims Processing Timeliness  80.1 -  Control and Counting Claims  80.2 -  Definition of Clean Claim  80.2.1 -  Receipt Date  80.2.1.1 -  Payment Ceiling Standards  80.2.1.2 -  Payment Floor Standards  80.2.2 -  Interest Payment on Clean Non- PIP Claims Not Paid Timely  80.2.2.1 -  Determining and Paying Interest  80.2.2.2 -  Preparation of IRS Form 1099- INT 80.3 -  Other Claims (other than clean)  80.3.1 -  Incomplete or Invalid Claims Processing Terminology 80.3.2 -  Handling Incomplete or Invalid Claims  80.3.2.1.1 -  A/B MAC (B) Data Element Requirements  80.3.2.1.2 -  Conditional Data Element Requirements for A/B MACs (B) and DME  MACs  80.3.2.1.3 -  A/B MAC (B) Specific Requirements for Certain Specialties/Services  80.3.2.2 -  Consistency Edits for Institutional Claims  80.3.3  Timeliness Standards for Processing Other -Than -Clean Claims  80.4 -  Enforcement of Provider Billing Timelines and Accuracy Standard to Continue PIP (Periodic Interim Payment)  80.5 -  Do Not Forward Initiative (DNF)  80.5.1 -  Carrier DNF Requirements  80.5.1.1 -  Reporting Requirements -  Carriers  80.6 -  Processing All Diagnosis Codes Reported on Claims Submitted to Carriers  90 - Patient Is a Member of a Medicare Advantage (MA) Organization for Only a Portion of the Billing Period  91 - Moral and Religious Fee for Service Claims for Medicare Beneficiaries Enrolled in Certain Medicare Advantage (MA) Plans  100 -  Medicare as a Secondary Payer  110 -  Provider Retention of Health Insurance Records  110.1 -  Categories of Health Insurance Records to Be Retained  110.2 -  Microfilming Records  110.3 -  Retention Period 110.4 -  Destruction of Records  120 -  Detection of Duplicate Claims  120.1 -  Overview  120.2 -  Exact Duplicates  120.3 -  Suspect Duplicates  130 -  Adjustments and Late Charges  130.1 -  General Rules for Submitting Adjustment Requests  130.1.1 -  Adjustment Bills Involving Time Limitation for Filing Claims  130.1.2 -  Claim Change Reasons  130.1.2.1 -  Claim Change Reason Codes  130.1.2.2 -  Edits on Claim Change Reason Codes  130.1.2.3 -  Additional Edits  130.1.3 -  Late Charges  130.2 -  Inpatient Part A Hospital Adjustment Bills  130.2.1 -  Tolerance Guidelines for Submitting Inpatient Part A Hospital Adjustment Requests  130.3 -  SNF Part A Adjustments  130.3.1 -  Tolerance Guides for Submitting SNF Inpatient Adjustment Requests  130.3.2 -  SNF Inpatient Claim Adjustment Instructions  130.3.3 -  Patient Does Not Return From SNF Leave of Absence, and Last Bill Reported Patient Status as Still Patient (30)  130.4 -  Hospital and SNF Part B Adjustment Requests  130.4.1 -  Guidelines for Submitting Adjustment Requests  130.5 -  Home Health Adjustments  130.5.1 -  Submitting Adjustment Requests  130.6 -  Adjustments to Reprocess Certain Claims Denied Due to an Open Common Working File (CWF) Medicare Secondary Payer (MSP) Group Health Plan (GHP) Record Where the GHP Record Was Subsequently Deleted  or Terminated  130.7 -  MAC Guidance Related to Use of Adjustment Codes on Adjustment Claims  140  Fiscal Intermediary (FI) Edits Affecting Multiple Bill Types  140.1 -  Threshold Edit for Outpatient and Inpatient Part B Claims  140.2  Systematic Validation of Claims Information Using Patient Assessments  140.3 -  Verification Edit for Claims with OPPS Payments  150  Limitation of Liability Notification and Coordination With Quality Improvement Organizations (QIOs)  150.1 -  Limitation on Liability -  Overview  150.2  Hospital Claims Subject to Hospital Issued Notices of Noncoverage  150.2.1  Scope of Issuance of Hospital Issued Notices of Noncoverage (HINNs)  150.2.2 -  General Responsibilities of QIOs