General Billing Requirements, Chapter 1, Medicare Claims Processing Manual
Chapter 1, “General Billing Requirements,” explains an array of basic information, including but not limited to: The formats for submitting claims to Medicare; Jurisdictions for claims; Provider assignment to Medicare administrative contractors; Provider participation; Termination of provider agreements; The basic process for filing a request for payment, including the rules for billing frequency; Billing noncovered charges on institutional claims; Part A and Part B timely filing limits and exceptions; MAC claims processing timeliness; How to handle billing when a patient is a Medicare Advantage enrollee for a portion of the billing period; duplicate claims; SNF Part A and Part B adjustment billing; SNF claims subject to expedited determinations; and Services paid on the Medicare Physician Fee Schedule for SNF Part B claims (22x and 23x bill types).
Administration & Registration Requirements, Chapter 2, Medicare Claims Processing Manual
Chapter 2, “Administration and Registration Requirements,” explains basic information, including but not limited to: General administration and registration rules, including health insurance claim numbers (HICN) and SNF verification of prior hospital stay information for determining deductible and benefit period status; Information required to determine whether to bill Medicare or another payer; and Providers obtaining/verifying the HICN and entitlement status, including the rules for accessing eligibility data from systems maintained by CMS and the Medicare administrative contractors.
Part B Outpatient Rehabilitation, Chapter 5, Medicare Claims Processing Manual
Chapter 5, “Part B Outpatient Rehabilitation and CORF/OPT Services,” includes information about the annual Part B financial limitations, as well as instructions on functional reporting and HCPCS coding requirements, including reporting service units and using timed codes. In addition, the chapter has an appendix with relevant ICD-10 codes.
SNF Inpatient Part A Billing and Consolidated Billing, Chapter 6, Medicare Claims Processing Manual
Chapter 6, “SNF Inpatient Part A Billing and SNF Consolidated Billing,” provides nuts-and-bolts information on SNF PPS billing and consolidated billing.
SNF Part B Billing, Chapter 7, Medicare Claims Processing Manual
Chapter 7, “SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule),” reviews the three situations where SNFs are allowed to submit claims for Part B services; billing for inpatient SNF Services paid under Part B; billing for outpatient SNF services; determining how much to charge before billing is submitted; general payment rules and application of Part B deductible and coinsurance; HCPCS codes; billing formats and frequency; guidelines for submitting corrected bills; and billing requirements for an array of services, such as bone mass measurements, supplies (e.g., surgical dressings), and durable medical equipment.
Preventive and Screening Services, Chapter 18, Medicare Claims Processing Manual
Chapter 18, Preventive and Screening Services,” reviews the coverage and billing rules for multiple preventive services, including the pneumococcal pneumonia, influenza virus, and hepatitis B vaccines, as well as various screening services such as mammography screening.
Completing & Processing the CMS-1450 or UB-04, Chapter 25, Medicare Claims Processing Manual
Chapter 25, “Completing and Processing the Form CMS-1450 Data Set,” provides a field-by-field look at the coding requirements for creating an accurate institutional Part A/B bill to submit to Medicare administrative contractors.
Common Working File (CWF) Technical Basics, Chapter 27, Medicare Claims Processing Manual
Chapter 27, “Contractor Instructions for the CWF,” explains how the Common Working File operates from a technical perspective and explains the meaning of various codes, such as SNF consistency error codes.
Appeals of Claims Decisions, Chapter 29, Medicare Claims Processing Manual
Chapter 29, “Appeals of Claims Decisions,” walks through the administrative appeals process. Topics include but are not limited to: Who may appeal; Steps in the appeals process, as well as a detailed review of each level: redetermination, reconsideration, administrative law judge hearing, departmental appeals board/appeals council, and U.S. District Court review; Where to appeal; Time limits for filing appeals and good cause for extension of the time limit for filing appeals; Amount-in-controversy requirements; Appointment of representative and assignment of appeal rights; Fraud-and-abuse issues; Guidelines for writing appeals correspondence; and Disclosure of information.
Financial Liability Protections: ABN, SNF ABN, NOMNC, Chapter 30, Medicare Claims Processing Manual
Chapter 30, “Financial Liability Protections,” explains multiple aspects of financial liability protections for patients, including but not limited to: Limitation on liability when claims are disallowed; The rules for determining financial liability when claims are disallowed; Requirements, including content and delivery rules, for Form CMS-R-131, the Advance Beneficiary Notice of Noncoverage (ABN); Requirements, including content, delivery, and signature rules, for Form CMS-10055, the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN); Indemnification procedures for claims falling within the limitation on liability provision; and Expedited determinations of provider service terminations , including the requirements for the Notice of Medicare Non-Coverage (NOMNC) and the Detailed Explanation of Non-Coverage. This section includes an example of an expedited determination scenario in a SNF.
Reopening & Revision of Claim Determinations and Decisions, Chapter 34, Medicare Claims Processing Manual
Chapter 34, “Reopening and Revision of Claim Determinations and Decisions,” explains the opportunities providers have to request a remedial action from Medicare contractors to change a final determination or decision that resulted in either an overpayment or an underpayment, even though the determination or decision was correct based on the evidence of record. Reopenings are separate and distinct from the appeals process. Topics include but are not limited to time frames to reopen claim determinations and what is good cause for reopening.