skip to content
Thank you for visiting First Coast Service Options' Medicare provider website. This website is intended exclusively for Medicare providers and health care industry professionals to find the latest Medicare news and information affecting the provider community.
To enable us to present you with customized content that focuses on your area of interest, please select your preferences below:
Select which best describes you:
Select your location:
Select your line of business:
This website provides information and news about the Medicare program for health care professionals only. All communication and issues regarding your Medicare benefits are handled directly by Medicare and not through this website. For the most comprehensive experience, we encourage you to visit or call 1-800-MEDICARE. In the event your provider fails to submit your Medicare claim, please view these resources for claim assistance.
Join eNews       En Español
Text Size:
YouTube LinkedIn Email Print
Send a link to this page
[Multiple email adresses must be separated by a semicolon.]
Last Modified: 11/23/2022 Location: FL, PR, USVI Business: Part A

Inpatient admitted prior to entitlement

Q: What are the claim submission rules for a beneficiary who is admitted into a hospital prior to their Medicare Part A effective date?
A: There are special billing guidelines to follow when the beneficiary becomes entitled to Part A benefits in the middle of an inpatient stay. Pre-entitlement days are not counted for utilization or for the hospital’s inpatient prospective payment system (PPS) pricer. Furthermore, pre-entitlement days are not used for the cost report or for utilization in non-PPS hospitals, exempt units, or skilled nursing facilities (SNFs). In this situation, the days are calculated based on the beneficiary’s Medicare Part A entitlement date through discharge/transfer/death.
The hospital may not bill the beneficiary or other persons for days of care preceding entitlement, except for days in excess of the outlier threshold. The hospital may charge the beneficiary or other persons for applicable deductible and/or coinsurance amounts.
Listed below are the claim submission guidelines for inpatient hospital admitted to discharge claims (no outlier):
Type of bill (TOB) -- Enter 111
Admitted date -- Enter the actual date of admission
Do not enter the Medicare Part A entitlement date as the admit date
Statement coverage period “From” date -- Enter the Medicare Part A entitlement effective date
Do not enter the admitted date as the coverage period “From” date
Statement coverage period “Through” date -- Enter the end date of the inpatient stay
Utilization days -- Enter the total number of days for the statement coverage period
Do not report any pre-entitlement days as covered or non-covered
Covered and non-covered days are reported utilizing value codes 80, 81, 82, and/or 83
Value code 80 -- Covered days
Value code 81 -- Non-covered days
Value code 82 -- Co-insurance days
Value code 83 -- Lifetime reserve days
Diagnosis codes -- enter all ICD-10-CM diagnosis codes from admission to discharge/transfer/death
Procedure codes -- enter all ICD-10-PCS procedure codes and dates from admission to discharge/transfer/death
Accommodation days/units -- Enter the appropriate number of units and charges as covered and/or non-covered for the statement coverage period
Do not report the pre-entitlement days as covered or non-covered room and board units or charges
Revenue codes -- 010X – 016X are appropriate for billing room and board
Revenue code -- 018X is appropriate for billing a leave of absence (non-covered days and charges)
Remarks -- Medicare Part A effective xx/xx/xx
The patient is admitted on April 25, 2022 and discharged on May 13, 2022. The patient’s Medicare Part A entitlement effective date is May 1, 2022. The claim should be billed as follows:
TOB -- 111
Admit date -- April 25, 2022
Statement coverage period “From” date – May 1, 2022
Statement coverage period “Through” date -- May 13, 2022
Utilization days -- 12 covered days
Accommodation days/units -- 12 covered units and covered charges
Remarks -- Medicare Part A effective May 1, 2022
Source: CMS internet-only manual, Publication 100-04, Chapter 3 external pdf file, Section 40; Chapter 25 external pdf file; MLN Matters® article SE1117 external pdf file
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.