Reason Code U538H - JE Part A

Reason Code Narrative

SERVICES BILLED WHILE BENEFICIARY IS INCARCERATED. MEDICARE DOES NOT PAY FOR THESE SERVICES BECAUSE THEY ARE PAYABLE BY ANOTHER GOVERNMENT AGENCY. SUBMIT CLAIM TO THAT AGENCY.

Common Reason Code Errors

• Beneficiary is incarcerated or is in custody of Federal, State, or Local authorities
  • Examples of this include but are not limited to:
    • Under Arrest
    • Incarcerated
    • Imprisoned
    • Escaped from confinement
    • Under supervised release
    • On medical furlough
    • Required to reside in mental health facilities
    • Required to reside in halfway houses
    • Required to live under home detention
    • Confined completely or partially in any way under a penal statute or rule

Note: CMS presumes that a state or local government that has custody of a Medicare beneficiary under a penal statute has a financial obligation to pay for the cost of healthcare items and services.

Common Reason Code Corrections

• Check for ineligible period due to incarceration via the Noridian Medicare Portal
• Contact the State Department of Corrections (or other site of incarceration) for payment
• If the beneficiary was not actually incarcerated during the claim dates of service, the beneficiary must update his/her status with Medicare and SSA

Resources

• CMS Change Request (CR) 8007
• CMS Internet Only Manual (IOM), Publication 100-04, Chapter 1, Section 10.4
• Patients in Custody Under a Penal Authority - MLN Fact Sheet

View reason code list, return to Reason Code Guidance page.