Claims FAQs

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

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 

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