Claims FAQs

No. A request must be submitted in writing. Click here for instructions.

Under certain circumstances, yes. The beneficiary may complete an appointment of representative form (CMS-1696). This form is used to authorize an individual to act as a beneficiary’s representative in connection with a Medicare appeal. 

Although some parties may pursue a claim or an appeal on their own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during the processing of a claim or claims, and/or any subsequent appeal. 

The following is a list of the types of individuals who could be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only: 

• Congressional staff members,
• Family members of a beneficiary,
• Friends or neighbors of a beneficiary,
• Member of a beneficiary advocacy group,
• Member of a provider or supplier advocacy group,
• Attorneys, and
• Physicians or suppliers.

Reference

• CMS IOM 100-4 Chapter 29 Section 270.1.1

It is crucial that beneficiary identification information submitted on claims is identical to the information found on the beneficiary's most recent Medicare card. Make a copy of the Medicare card for your records. 

• If you are a laboratory, radiology department, or other entity to which the patient or their service(s) may have been referred, obtain a copy of the patient's Medicare card from the referring source prior to submitting your claim and verify the information indicated below.

Use the beneficiary's Medicare card to verify the following:

• Medicare Beneficiary Identifier (MBI): Verify the beneficiary's MBI, ensuring it has not been changed.

• Beneficiary's name: Verify the beneficiary's name indicated on your claim is exactly as it reads on their Medicare card. For example, do not indicate "Betty" if the card reads "Elizabeth."

• Effective date: Verify the effective date of coverage.

• Part A and/or Part B: Verify which part of the Medicare program the beneficiary is enrolled, either A or B or both.

Eligibility dates: Click here for ways to verify current and previous dates of service eligibility.

Reference

• CMS IOM Pub. 100-09 MAC Beneficiary and Provider Communications Manual, chapter 6, section 50.1

Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or their representative may elect or revoke Medicare hospice care at any time in writing. The hospice entity cannot revoke the beneficiary’s election, nor request or demand that the patient revoke their election. If the patient revokes their hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the original Medicare program. 

Claim submittal for patients involving hospice election

When a beneficiary elects hospice during an inpatient stay: 

• Bill traditional Medicare for the period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill the hospice entity for the period of care after hospice election

When a patient revokes hospice election during an inpatient stay:

• Bill the hospice entity for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement 'From' date is the same as the hospice revocation date

For additional information review our FAQ on Reject reason code C7010.

Reference

• CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 9

To access the status of a claim or a beneficiary's Medicare eligibility information (including the date of birth, date of death, entitlement dates, benefit dates, deductible, or coinsurance) use these options below.

Prior to providing services, obtain a copy of the beneficiary's Medicare card and verify the beneficiary's insurance information with either the beneficiary or their legal representative. 

Eligibility information through SPOT

First Coast offers such access through SPOT. With SPOT, providers may access Part A and Part B eligibility status as well as benefit eligibility for preventive services, deductibles, therapy caps, inpatient, hospice and home health, Medicare secondary payer (MSP), plan coverage data categories and claim status up to twelve months from the date of the inquiry.

Other options for determining beneficiary eligibility

Part A providers

• Contact the Part A interactive voice response (IVR) system at 877-602-8816.
• 270/271 eligibility transactions -- this is also a real time inquiry, and you can obtain the eligibility information in a batch format for several beneficiaries.

Part B providers

• Contact the Part B IVR at 877-847-4992.

Note: Customer service representatives cannot assist you with eligibility information and are required, by CMS, to refer you to the IVR. The IVR can access information up to 27 months from the date of the inquiry.

Source: CMS IOM Pub. 100-09 MAC Beneficiary and Provider Communications Manual, chapter 6, section 50.1 

While providers and facilities are required and expected to work together to resolve the billing issue, providers may occasionally require assistance from the MAC. In that case, First Coast will work with both the provider and the facility for resolution. In addition, when the overlapping claim is processed by another MAC, First Coast will work with that other MAC.

Complete and submit 'Request for Assistance Form'

You may request assistance from First Coast to resolve your overlapping claims. Please complete, print and fax:

• Request for Assistance Form
• Supporting documentation must be included with your request
• Fax to the First Coast Claims Department, at 904-361-0784 

Note: Use a separate form for each request. This will enable First Coast to return each claim as it is completed, instead of holding claims until all claims on the request have been completed.

Upon receipt of the 'Request for Assistance Form', First Coast will take appropriate action within 30 calendar days. When First Coast is unable to complete the request within 30 days, we will provide a status and the reason for the delay on a copy of the request form. If you do not receive a status or response within 30 days of faxing the form, please submit a follow up request.

Reference

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 27, sections 50-50.3

Yes, the Cost Outlier timetable example is designed to assist providers in determining if a claim qualifies as cost outlier. Prior to coding an inpatient cost outlier claim, first determine the diagnosis related group (DRG) cutoff date, by using the example timetable.

Definitions

• Cost outlier -- an inpatient hospital discharge that is extraordinarily costly. Hospitals may be eligible to receive additional payment for the discharge. Section 1886(d)(5)(A) of the social security act provides for Medicare payments to Medicare-participating hospitals in addition to the basic prospective payments for cases incurring extraordinarily high costs.
  • To qualify for outlier payment, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments to qualify for outliers).
    • Total covered charges for an inpatient admission are $100,000 (hospital costs)
    • The prospective payment system (PPS) threshold amount for the DRG is $65,000 (fixed-loss threshold amount)
• CMS publishes the outlier threshold amounts in the annual inpatient prospective payments system (IPPS) final rule. Providers may access CMS' website to download the IPPS pricer.
• Inlier -- a case where the cost of treatment falls within the established cost boundaries of the DRG payment. To determine if the inpatient hospital claim meets the criteria for cost outlier reimbursement, two pieces of information are needed: 1) total covered charges and 2) PPS threshold amount. If the total covered charges exceed the PPS threshold amount, follow the coding rules for inpatient cost outlier claims.
• DRG cutoff day -- the "To" date or "End" date of the inlier period. Once the PPS threshold amount is known add the daily covered charges incurred by the patient until determining the day that covered charges reach the cost outlier threshold amount. Exclude days and charges during non-covered spans (e.g., occurrence span code 74 [non-covered level of care], 76 [patient liability], 79 [payer code] dates).
• Occurrence code (OC) 47 -- a code that indicates the first day the inpatient cost outlier threshold is reached or the date after the DRG cutoff date. For Medicare purposes, a beneficiary must have regular coinsurance and/or lifetime reserve days available beginning on this date to allow coverage of additional daily charges for the purpose of making cost outlier payments. OC47 date cannot be equal to or during dates coded for occurrence span code 74, 76, or 79. Click here for an example.
• Occurrence code A3 -- (Benefits exhausted) the last date for which benefits are available and after which no payment can be made.
• Occurrence span code 70 -- a code and span of time that indicates the from and through dates during the PPS inlier stay for which the beneficiary has exhausted all regular days and/or coinsurance days, but which is covered on the cost report. Click here for an example.
• Condition code 61 -- a code that indicates this bill is a cost outlier. Click here for an example.
• Condition code 67 -- a code that indicates the beneficiary has elected not to use lifetime reserve (LTR) days.
• Condition code 68 -- a code that indicates the beneficiary has elected to use lifetime reserve (LTR) days.

References

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual: Chapter 3, section 20.7.4 and Chapter 25 

If the patient is enrolled in a Medicare Advantage plan, contact the Medicare Advantage plan prior to rendering services to determine what amount the patient is responsible for out of pocket. This will provide you guidance on whether to treat or bill the patient. Medicare does, however, limit the amount providers can bill patients for services. Refer to Medicare & You handbook more information.

When a patient enrolled in a Medicare Advantage plan uses out-of-network providers, their out-of-pocket expenses for covered services may be higher. It is important to verify with the patient (and confirm through First Coast’s Part B interactive voice response (IVR) system at 1-877-847-4992 or through SPOT) if the patient is enrolled in a Medicare Advantage plan. 

The CMS IOM Pub. 100-16, Medicare Managed Care Manual, Chapter 4 - Benefits and Beneficiary Protections, Section 110.1.3 states:

• Medicare Advantage plans must reimburse non-participating providers for emergency care, ambulance services sought through 911 calls, and for medically necessary dialysis services from a non-participating provider when the patient is out of the service area.

The CMS IOM Pub. 100-16, Medicare Managed Care Manual, Chapter 6 - Relationships with Providers, Section 100 further states:

• Non-contracted providers must accept as payment in full no amount greater than what original Medicare would pay and cannot bill the patient more than their normal cost-sharing amounts (coinsurance).

There are numerous potential scenarios and the answer may change dependent upon terms of the plan. In general, if a Medicare Advantage plan enrollee seeks care outside of the Medicare Advantage plan network in which he or she is enrolled and the Medicare Advantage organization sponsoring the plan has no legal liability for reimbursement, then yes, the provider can bill the Medicare Advantage plan enrollee. However, the provider shouldn't bill the patient more than the original Medicare amount for what would otherwise be covered A/B services.

There is no specific guidance for collecting payment from the patient at the time services are rendered.

Reference

• CMS IOM Pub. 100-16, Medicare Managed Care Manual, Chapters 4 and 6 

Claims for inpatient hospital and skilled nursing facility (SNF) services have priority over claims for home health services because beneficiaries cannot receive home care while they are institutionalized. A beneficiary cannot be institutionalized and simultaneously receive home care.

• Verify dates of service (DOS) on your claim
  • If DOS are incorrect, correct your claim and resubmit.
  • If DOS are correct, it is recommended you contact the home health agency and ask them to correct their claim.
• Edit exclusions:
  • The inpatient claim admission date is the same as the home health agency transfer / discharge date
  • The inpatient claim discharge date is the same as the home health agency admission date
  • The inpatient claim dates are between the occurrence span code 74 ‘From’ date and the day following the occurrence span code ‘Through’ date

Refer to resolution tips for overlapping claims, which is the A/B and home health and hospice (HHH) MAC collaborative job aid on how to resolve and prevent overlapping claim situations.

Reference

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 10, section 30.9 and Chapter 25 

Yes, we encourage you to code the claim appropriately when submitting it the first time. You have access to CMS PRICER software which helps you determine the prospective payment system (PPS) threshold. Once you determine the PPS threshold and confirm the claim can be submitted as a cost outlier, you should code the claim appropriately and forward to the Fiscal Intermediary Standard System (FISS).

To determine if the inpatient hospital claim meets criteria for cost outlier reimbursement, you need two pieces of information:

• Total covered charges, and
• PPS threshold amount

If the total covered charges exceed the PPS threshold amount by CMS’ published standards for the current year, then you should follow the coding rules for inpatient cost outlier claims.

Reference

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual: Chapter 3-Inpatient Hospital Billing, Sections 20.1.2 and 20.7.4, Chapter 25-Completing and Processing the Form CMS-1450 Data Set 

Federal regulations require that MACs maintain payment responsibility for managed care enrollees who elect hospice. 

While a hospice election is in effect, certain types of claims may be submitted to the MAC by either the hospice provider or a provider treating an illness not related to the terminal condition. The claims are subject to Medicare rules of payment.

• Hospice services covered under the Medicare hospice benefit are billed by the Medicare hospice.
• Institutional providers may submit claims to Medicare with the condition code "07" when services provided are not related to the treatment of the terminal condition.
• Medicare Advantage plan enrollees that elect hospice may revoke hospice election at any time, but claims will continue to be paid by the MAC as if the beneficiary were enrolled in Medicare until the first day of the month following the date hospice election was revoked.
  • Example:
    • Beneficiary's hospice election period ended on 1/10/YY
    • Bill the MAC for claims for DOS 1/11/YY to 1/31/YY
    • Bill the Medicare Advantage plan for claims for DOS 2/1/YY and beyond

Refer to resolution tips for overlapping claims, which is the A/B and home health and hospice (HHH) MAC collaborative job aid on how to resolve and prevent overlapping claim situations.

Reference: 

• CMS IOM, Pub. 100-04 Medicare Claims Processing Manual, Chapter 11, section 30.4, 50 

The “payment floor” is a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. There are different waiting periods for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 28 days for paper claims. However, the payment may not be issued until day 14 (electronic) or 29 (paper).

A “clean” claim is one that does not require the carrier or fiscal intermediary to investigate or develop external to their Medicare operation on a prepayment basis. Clean claims must be filed in the timely filing period.

References

• CMS IOM, Pub 100-04, Chapter 1, Section 80.2.1.2
• CMS IOM, Pub 100-04, Chapter 1, Section 80.2

Medicare Secondary Payer (MSP) overpayments are processed differently than non-MSP overpayments and require a refund to be sent within sixty days of receiving a duplicate payment. Complete the appropriate Medicare Secondary Payer return of monies voluntary refund form (see below) and attach a check for the overpaid amount. In addition, the other insurer’s explanation of benefits and/or payment information is required for every claim involved.

• Return of Monies Voluntary Refund Form

Refer to the Medicare Secondary Payer FAQs for more information on MSP overpayments and how to determine the MSP overpayment amount. 

Reference

 Code of Federal Regulations, 42 CFR 411.24
 

Once an overpayment has been determined, providers are required to repay the debt. Complete the overpayment refund form (see below) and attach a check for the amount. Specific data such as patient name, Medicare ID # and Medicare claim number must be included for claim correction and remittance revision, where appeal rights are afforded. If this data is not returned and Medicare is unable to correct records, claim(s) included in the refund may be identified as an overpayment and demanded in the future.

• Return of monies voluntary refund form

Reference

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//fin106c05.pdf 
 

An overpayment letter is a formal request to repay a debt owed to the Medicare Trust Fund. Payment is due upon receipt of the notice. Send the payment with a copy of the overpayment letter received or request an immediate offset.  Interest will accrue 30 days from the date on the overpayment letter and every thirty days thereafter. On day 40, we will immediately begin offsetting and claim payments will be withheld and applied until the entire debt is collected.

The letter number or AR number must be included with the payment in order to apply the refund properly, without delay.

Reference

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/fin106c03.pdf
 

For services payable under the Medicare Physician Fee Schedule (MPFS) and anesthesia services, report the name and complete address (including ZIP code) of the physical location where services were rendered in Item 32. This information needs to be completed for all paper claims submitted to Medicare. Report a nine-digit ZIP code (instead of five digits) if the physical location is in an affected locality, as identified in the CMS IOM Pub. 100-04 Medicare Claims Processing Manual, chapter 1, section 10.1.1- 10.1.1.1. 

* Click here to see if a nine-digit ZIP code is needed for the facility. 

The service facility location ID (Item 32a of the paper claim form) is only used for the NPI of providers who render a purchased service. For details pertaining to purchased diagnostic tests, please refer to the Indicating the TC of a diagnostic service FAQ on the First Coast provider website. 

* Note: No information should be entered in Item 32b of the paper claim, as it is no longer used. Claims will be returned as unprocessable if any information appears in Item 32b. 

Reference 

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 1, Section 10.1.1-10.1.1.1 and Chapter 26, Section 10.4 

After notice of a valid appeal request, if limitation of recoupment (Section 935 of the Medicare Modernization Act) provisions apply, all collection activities are ceased, including the withholding of future claim payments. Interest, however, will continue to accrue during the appeal process.

Reference

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R141FM.pdf

Please take a few minutes to let us know about your experience with the redeterminations process.
 

An Extended Repayment Schedule (ERS) can be requested if the debt cannot be paid in full. Follow instructions outlined in the Sole proprietor or Corporation/group ERS forms below and return the required documentation.  Once a completed ERS has been received, a 30 percent withholding of claim payments will begin, and the withholding will continue until the review has been completed. The original documents must be mailed with the payment. Once approved, all ERS payments will be recouped from the provider’s future Medicare payments according to the approved amortization schedule, unless it has been determined that there is a valid reason for the provider to send a check.

• Sole proprietor ERS form
• Corporation/group ERS form 

Reference

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/fin106c04.pdf 
 

An overlap is when an incorrect claim is processed and posted to the Common Working File (CWF) resulting in claim overlap rejection(s) of subsequent claim(s) submitted by the same or a different provider. When more than one provider is involved, the providers must work together to resolve the error. Some overlapping claim examples include:

• Same provider -- dates of service overlap
  • Charges should be combined on one claim
  • Outpatient claim submitted before allowing time for inpatient claim(s) to finalize
  • Claims should be submitted in service date sequence
• Different provider -- dates of service overlap
  • Did not report a leave of absence on the claim
  • Services are subject to consolidated billing
  • Incorrect patient status code was submitted

Refer to resolution tips for overlapping claims, which is the A/B and home health and hospice (HHH) MAC collaborative job aid on how to resolve and prevent overlapping claim situations.

Reference

• CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, Section 120.3 

Per Medicare guidelines, claims must be filed with the appropriate Medicare claims processing contractor no later than 12 months (one calendar year) after the date of service (DOS). Claims must be processed (paid, denied, or rejected) by Medicare to be considered filed or submitted. Claims with missing, invalid or incomplete information that prevents Medicare from processing them, also known as "returned to provider (RTPs)" (Part A) and "rejected as unprocessable claims" (Part B), are NOT considered filed or submitted. These claims must be corrected and resubmitted for processing. Claims rejected, returned or rejected as unprocessable will affect timely filing. Claims submitted after one calendar year from the DOS will be denied or rejected.

Some examples of reject and denial codes you may receive for timely filing include:

• Part A: Reject reason code 39011
• Part B: CO 29

Key points to prevent this denial or reject

For all claims

• Claims with a February 29 DOS must be filed by February 28 of the following year to be considered filed timely.
• Electronic claims -- The electronic data interchange (EDI) system accepts claims 24/7; however, claims received after 6 p.m. ET or on a weekend or holiday are considered received the next business day.
• Paper claims -- Timeliness is calculated based on contractor receipt date, not the postmark date when the claim was mailed, so please allow time for mailing.

For claims with "span dates of service" ("from" and "through" date span on the claim)

• Part A institutional claims – "Through date" is used to determine the DOS for claim timely filing.
• Part B claims – "From date" is used to determine the DOS for claim timely filing.

Exceptions allowing extension of time limit

• Exceptions to the 12-month timely filing period are limited and very specific as outlined in the CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 1, Section 70.

References 

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 1, Section 70
• Section 6404, Patient Protection and Affordable Care Act (PPACA)
• Code of Federal Regulations Title 42 CFR 424.44 - Time limits for filing claims (http://www.ecfr.gov )

Reference the Outlier Flowchart after asking this question: Does the cost for an inpatient stay exceed the cost outlier threshold amount?

• If no -- submit claim as regular inpatient claim.
• If yes -- are there enough benefit days (regular or lifetime reserve) to cover the medically necessary days?
  • If yes -- submit claims as regular inpatient claim. Do not indicate occurrence code 47.
  • If no -- indicate occurrence code 47 and date of the first full day of cost outlier status (the day after the day that covered charges reach the cost outlier threshold).
    • For Medicare purposes, cost outlier payments are paid for each day during the outlier period that the beneficiary has an available benefit day (regular, coinsurance, and/or lifetime reserve).
    • Diagnosis related group (DRG) claims without cost outlier payments can never have regular benefit days combined with lifetime reserve benefit days. When regular benefit and lifetime reserve days are billed on the same claim, lifetime reserve usage begins on the cost outlier date (should be equal to occurrence code 47 date).

Definitions:

Occurrence code 47 -- indicates the first day the inpatient cost outlier threshold is reached or the date after the DRG cutoff date. For Medicare purposes, a beneficiary must have regular coinsurance and/or lifetime reserve days available beginning on this date to allow coverage of additional daily charges for the purpose of making cost outlier payments. Occurrence code 47 cannot be equal to or during the dates of occurrence span code 74 or 76.

Occurrence span code 74 -- the from/through dates for a period at a non-covered level of care in an otherwise covered stay, excluding any period reported with occurrence span codes 76, 77, or 79. Codes 76 and 77 apply to most non-covered care. Used for leave of absence or for repetitive part B services to show a period of inpatient hospital care or outpatient surgery during the billing period. Also used for home health association (HHA) or hospice services billed under part A, but not valid for HHA under prospective payment system (PPS).

Occurrence span code 76 -- the from/through dates for a period of non-covered care for which the provider is permitted to charge the beneficiary. Codes should be used only where the MAC or fiscal intermediary (FI) of the quality improvement organization (QIO) has approved such charges in advance and the patient has been notified in writing three days prior to the ‘from’ date of this period.

 References

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 3-Inpatient Hospital Billing, Section 20.7.4 and Chapter 25-Completing and Processing the Form CMS-1450 Data Set 

OSC70 should be coded on the cost outlier claim when the beneficiary’s benefit days have exhausted and there are extra days within the inlier portion of the claim. The claim may be paid up to the diagnosis related group (DRG), as long as there are benefit days remaining for the claim.

Answering this question will assist in submitting the claim correctly. Did the beneficiary’s regular, coinsurance or lifetime reserve days exhaust during the inlier portion of the stay?

• If no -- submit claim as regular inpatient claim or follow guidelines for using occurrence code 47 and A3, if applicable.
• If yes --
  • Did the regular benefit days exhaust during the inlier period?
    • Indicate occurrence span code 70.
• Did lifetime reserve days exhaust during the inlier period? Note: Lifetime reserve days can be billed only in the inlier period when these are the only benefit days available at the time of admission.
  • The from and through dates should represent the period of time during the prospective payment system (PPS) inlier stay for which the benefit days are exhausted.

If a beneficiary has at least one regular benefit day remaining in the benefit period available for use at the time of admission, the entire stay up to the DRG cutoff will be paid for by Medicare.

All charges for dates within the occurrence span code 70 should be billed as covered.

Definition

OSC 70 -- Non-utilization dates (for payer use on hospital bills only). The from/through dates during a prospective payment system (PPS) inlier stay for which the beneficiary has exhausted all regular days and/or coinsurance days, but which is covered on the cost report.

Reference

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 3, section 20.7.4 and Chapter 25 

The POS code should be entered in the 2400 Place of Service Code loop (segment SV105) of the 837P electronic claim (Item 24B on the CMS-1500 paper claim form).

It is important to ensure you bill the appropriate POS code on all claims to avoid potential overpayments. It is recommended you review your claims and systems for proper billing of the place of service codes.

• If you use an outside billing agency or clearinghouse, make sure they are billing all your claims with the correct place of service code. It is your responsibility to ensure your claims are billed correctly.

References

• CMS IOM Pub. 100-04, Medicare Claims Processing Manual, chapter 26, sections 10.4 & 10.5
• CMS Place of Service Codes Overview

If the practitioner rendering the service is part of a billing group, report the individual practitioner’s NPI in the 'Rendering Physician #' area (2310B loop, segments NM108 [XX] and NM109 [NPI], of the 837P electronic claim or Item 24J of the CMS-1500 paper claim form).

• The NPI is required for all rendering providers. If the NPI is missing, invalid, or submitted in the wrong area (e.g., valid NPI submitted in the upper, shaded portion of Item 24J), your claims will be rejected as unprocessable.
• Note: If submitting claims on the CMS-1500 paper claim form, report the NPI of the individual practitioner in the lower, non-shaded portion of Item 24J. Do not place any information in the upper, shaded portion of Item 24J or your claim will be rejected as unprocessable.

If you are an independent lab, ambulatory surgical center (ASC), independent diagnostic testing facility (IDTF), ambulance supplier, or a solo practitioner not associated with a billing group, a rendering provider identifier is not required in the Rendering Physician # area when billing services. Report the NPI of these types of providers in the 837P 2010AA Billing Provider loop, segments NM 108 (XX) and NM109 (NPI) of the electronic claim or Item 33a of the paper claim form.

References

• CMS IOM Pub. 100-04, Medicare Claims Processing Manual, chapter 26, section 10.4 

The billing entity's NPI should be reported in the 2010AA Billing Provider Loop of the 837P electronic claim or Item 33a of the CMS-1500 paper claim form. 

Important note: The NPI of the billing provider is required on all claims. Paper claims will be rejected as unprocessable and electronic claims may be rejected if:

• Any information appears to be missing or invalid in the 837P 2010AA loop, REF02. Item 33b of the paper form should be left blank.
• The billing provider's NPI is missing, invalid, or is in the wrong area (e.g., valid NPI submitted in Item 33b.)

Reminder: When billing services rendered by an individual associated with an incorporated entity or a group, the individual practitioner's NPI must be reported in the Rendering Physician's area (the 2310B Rendering Provider Loop of the 837P electronic claim or Item 24J of the paper claim form) and the billing entity or group identifier would be reported as indicated above. If you are an independent lab, ambulatory surgical center (ASC), independent diagnostic testing facility (IDTF), ambulance supplier, or solo practitioner not associated with a group, a rendering provider identifier in Item 24J or loop 2310B is not required when billing services.

Reference

CMS IOM Pub. 100-04 Medicare Claims Processing Manual, chapter 26 section 10.4

Indicate the referring or ordering provider’s information in the section titled Name of referring provider or other source (Item 17 & 17b of the CMS-1500 paper claim form or the 2310A Referring Provider Loop, segments NM101 using qualifier DN or DK, NM103-NM105 [Name], NM108 using [XX] qualifier, and NM109 [NPI] of the 837P electronic claim) as indicated below.

• Report the name of the referring or ordering practitioner of a service in Item 17 (837P 2310A loop, segment NM1) and the appropriate qualifier to the left of the dotted line on the CMS-1500 (02/12) claim form: DN (referring provider) or DK (ordering provider)
• No information should appear in Item 17a (837P 2310A loop, segment REF02). Item 17a was formerly used to report the Unique Physician Identification Number (UPIN), which is no longer used -- leave this item blank. Information appearing in this item or loop will cause your claims to be returned as unprocessable and rejected electronically.
• Report the NPI of the referring/ordering provider in Item 17b or the 837P 2310A Referring Provider Loop, segments NM101 using qualifier DN (referring provider) or DK (ordering provider), NM103-NM105 [Name], NM108 using [XX] qualifier and NM109 [NPI].
  • Note: When a service is referred or ordered by another practitioner, a valid NPI is required and must be reported. Your claims will be returned as unprocessable if the NPI is required and is missing, invalid or submitted in the wrong item (e.g., a valid NPI submitted in Item 17a).

References

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 26, section 10.4
• Change request (CR) 8509 Form CMS-1500 Instructions: Revised for Form Version 02/12

Medicare Part B pays only for physician services not performed for the hospice-related condition or paid under arrangement with a hospice entity. Services related to the terminal condition are billed by the hospice facility to the appropriate home health intermediary (Part A). 

First Coast, as the jurisdiction N Part A and B MAC (JN A/B MAC), does not process claims for hospice services. Florida hospice claims are processed by Palmetto GBA as the regional home health intermediary (RHHI). National Government Services (NGS) is the RHHI responsible for Puerto Rico and the U.S. Virgin Islands. 

First Coast does process claims for Part B providers who provide services to patients who are in a hospice episode, but the providers are not employed by or paid under arrangement with the hospice entity or the services provided are not related to the hospice patient's terminal condition.

If the physician billing hospice-related services is not employed or paid through an arrangement by the hospice entity, the services should be billed with a modifier GV (which indicates "Attending physician not employed or paid under arrangement by the patient's hospice provider"). Physician services not related to the patient's hospice condition must be billed with modifier GW (which indicates "Service not related to the hospice patient's terminal condition").

Reference

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 11, section 40