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?

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).

The MSP Contractor consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The purpose of the COB program is to identify the health benefits available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken Medicare payment. The MSP Contractor does not process claims or claim-specific inquiries. The MACs are responsible for processing claims submitted for primary or secondary payment and resolving situations where a provider receives a mistaken payment of Medicare benefits.

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. 

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).

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. 

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.