Pre-Entitlement Claims for Inpatient Hospitals

Pre-Entitlement exists when a beneficiary is admitted to an acute care hospital stay prior to the beneficiary's Medicare entitlement effective date. In order to process these claims correctly, the claim must be submitted as follows:

Admit to Discharge claims (TOB 111)

  1. Original admission date form locator (FL 12)
  2. Statement Covered Period From Date (FL 6) equal to the effective date of Medicare coverage
  3. Statement Covered Period Through Date (FL 6) equal to the end date of the stay
  4. Covered days with value code 80 (FL 39-41) equal the from and through date span
  5. Include diagnosis codes (FL 66) since admission date
  6. Surgical Procedures (FL 74) performed since the admission date
  7. Include all charges since admission date excluding room and board prior to the effective date of Medicare

Interim Billing Claims (TOB 112-113)

  1. Original admission date form locator (FL 12)
  2. Statement Covered Period From Date (FL 6) equal to the effective date of Medicare coverage
  3. Statement Covered Period Through Date (FL 6) equal to the end date of the stay
  4. Covered days with value code 80 (FL 39-41) equal the from and through date span
  5. Include diagnosis codes (FL 66) from admission date
  6. Surgical Procedures (FL 74) performed since the admission date
  7. Include all charges since admission date excluding room and board prior to the effective date of Medicare

Additional Notes

  • Providers may not bill the beneficiary or other persons for days of care preceding entitlement except for days in excess of the outlier threshold.
  • Claims with a discharge date equal to the effective date of Medicare coverage cannot be billed as pre-entitlement claims.

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Last Updated Apr 09, 2018