Master Core Curriculum

1. Master Core Curriculum Part A Intermediate Module 1 Basics of Billing and Reimbursement

2. FFS Fee For Service RAPS Request for Anticipated Payment NOE Notice of Election RTP Return to Provider ABN Advance Beneficiary Notice COB Coordination of Benefits COBA Coordination of Benefits Agreement COBC Coordination of Benefits Contractor FI Fiscal Intermediary Acronyms

3. FISS Fiscal Intermediary Standard System PPS Prospective Payment System IRF Inpatient Rehabilitation Facility LTCH Long-term care hospitals IPF Inpatient Psychiatric Facility OP Outpatient TOB Type of Bill RA Remittance Advice ERA Electronic Remittance Advice HICN Health Insurance Claim Number Acronyms

4. Learning Outcomes At the end of the module, participants will be able to: • apply appropriate billing codes (tailored to your region) • articulate the differences between billing covered and non-covered services • verbalize the key points of the claims crossover process • recognize payment floor impact on reimbursement • sequence billing • identify key steps in the adjustments/cancellations processes • use appropriate claims processing reports

5. Inpatient and Outpatient Services • Definition of Inpatient Service • Requires a beneficiary reside in a specific institutional setting during treatment • Definition of Outpatient Service • Service is provided by an institutional provider but the beneficiary is not confined to a specific institution for period of 24 hours or more

6. Type of Bill (TOB) • Payment is associated with specific bill types • Fee For Service (FFS) bill types are 3 digits with the 3rd digit usually shown by an “X” that represents a varying third digit for that bill types • See attachment of FS Bill Types • Each bill type has specific claim submission requirements

7. at this point may want to insert slides with information that is specific to the audience that you are presenting to – for example, if audience is comprised of home health providers, add slides that address the specific billing codes they would use.

8. Covered and Non-covered Charges • Covered and non-covered charges can both appear on Medicare claims • Payment not requested • Must complete appropriate liability notices to establish payment liability • Example: Advance Beneficiary Notices, discussed in Chapter 3 • Determination of liability and notification of the beneficiary must occur prior to billing

9. Appeal Rights • Appeal rights apply • Non covered claims are considered denied claims • Should be used infrequently • Beneficiary cannot be held liable for services not properly billed to Medicare • No Medicare determination made • Example: Return to Provider (RTP) claim

10. Condition Codes • Condition Code 20 • ABN not required and beneficiary ‘demands’ a Medicare Determination • Beneficiary receives an official Medicare notice • Condition Code 21 • ABN not required; service is statutorily excluded service • Provider receives a Medicare denial to bill another insurer • Occurrence Code 32 • ABN required and beneficiary demands Medicare determination

11. Claims Crossover Process • CMS Coordination of Benefits (COB) program • Identifies health benefits available to Medicare beneficiaries • Coordinates the payment process • Ensures appropriate Medicare benefit payment

12. Claims Crossover Process • The COB program offers automatic crossover of Medicare paid claims • Other insurers • Trading partners • Medicare supplemental insurers • Title XIX State Medicaid agencies • Medigap insurers • Each insurer/trading partner enters into a national Coordination of Benefits Agreement (COBA) with the CMS designated Medicare Coordination of Benefits Contractor (COBC)

13. Payment Standards • Clean Claim • Do not require FI to investigate or request additional information prior to payment • Receipt Date • Paper claim • Date the claim is received in the FI mailroom • Electronic claim • Date the claim is ‘read into’ the FISS

14. Payment Floor • The minimum number of days an FI must wait before paying a clean claim • Electronic claims paid 14 days after the receipt date • Paper claims paid 28 days after the receipt date • Timeliness Standard • The maximum number of days the FI has to process a clean claim • Interest is paid beginning on the 31st day • Claims are considered ‘aging’

15. Frequency & Sequential Billing Requirements • TEFRA (cancer & children) hospital and SNF Inpatient claims • Frequency – when to submit a claim • beneficiary discharge • beneficiary’s benefits are exhausted • beneficiary’s level of care changes • monthly • Sequential – claims must be submitted in service date sequence

16. Frequency & Sequential Billing Requirements • Inpatient acute-care PPS hospitals, IRFs, LTCHs, IPFs • May interim bill in at least 60-day intervals • Subsequent bills must be in an adjustment bill format

17. Frequency & Sequential Billing Requirements • Outpatient Services billed to the FI • Repetitive Part B services to a single individual • Billed monthly or at conclusion of treatment • Use OC 72 to denote an inpatient stay, OP surgery or service that occur within the month period • May include clinical laboratory services on same bill • May not include other non-repetitive services • Bill one time Part B services upon completion of service

18. Frequency & Sequential Billing Requirements • Skilled Nursing Facility (SNF) • The SNFs bill upon the following: • Discharge; • Benefit exhaustion; • A decrease in level of care to less than skilled care; or • Monthly (and if necessary, monthly thereafter) • Claims must be submitted in sequence

19. Frequency & Sequential Billing Requirements • Hospice • Notice of Election • Monthly claims submitted in date of service order • Revocation/Discharge claim

20. Frequency & Sequential Billing Requirements • Home Health • Request for Anticipated Payment (RAP) • Final Claim

21. Adjustments • Type of Bill (TOB) is Xx7 • Submit to change information on a previously processed claim • Change must impact • Original processed bill or • Additional bills • Claim being adjusted must be in a finalized status • (P, D, R) • Appears on Remittance Advice (RA)/Electronic Remittance Advice (ERA) as a debit/credit

22. Adjustments • Do not submit adjustments when: • Claim has been denied by medical review • Is in the Return to Provider (RTP) File • When time limitation for filing a claim has expired

23. Adjustments • Cancel Only (Void) Adjustments (TOB XX8) • Acceptable when: • Incorrect provider number submitted • Incorrect HICN submitted • Duplicate payment was received • Processed RAP contains errors (HHA only) • Claim must be in a finalized status • Appears as a credit on RA/ERA

24. Claims Processing Reports • FISS Online • Access a variety of claims processing information • Inquiry Menu, ‘Claims’, Option 12 • 201 Report • Weekly report provided to non-electronic providers • Summary of pending claims • Not cumulative • Others • Detail claims being held on the payment floor • Provider profiles

25. Chapter Review Slide • What is the difference between an inpatient service and an outpatient service? • What two events must occur before billing a claim with non-covered charges? • What is the primary purpose of the Coordination of Benefits program? • What happens when claims are submitted out of sequence? • Name one type of claims processing report.

26. Chapter References/Citations • IOM CMS Pub. 100-4, Chapter 1, Medicare Claims Processing @ • www.cms.hhs.gov/manuals/104_claims/clm104c01.pdf • CMS Publication 100-4, Transmittal 98 @ • www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp

27. Chapter References/Citations • Medlearn Matters Number MM3109 @ • www.cms.hhs.gov/Medlearn/matters/ • CMS Forms @ • www.cms.hhs.gov/forms/default.asp • CMS-1450 Form @ • www.cms.gov/providers/edi/h1450.pdf