Military Treatment Facility (MTF)

Beginning July 6, 2022, hospitals electing to bill the program for emergency services on a calendar year basis may obtain beneficiary eligibility, claim status from the Noridian Medicare Portal (NMP). Enrollment to the portal is required and you will be prompted upon accessing the site.

Contact the PCC if you need any further information.

UB04 Billing

The UB04 form needs to be completed in its entirety, codes are available from the NUBC (www.nubc.org) via the NUBC’s Official UB-04 Data Specifications Manual. If required fields are not completed on the UB04 they will not load into our claims processing system correctly.

Here are some examples of items that are required:

Form Locators 39- 41 Value Codes and amounts:

  • Value codes 80 for covered days, 81 for non-covered days, 82 for co-insurance days, 83 for lifetime reserve days (LTR) and the number of days reported for each. Ex: value code 80 with 4 covered days would be listed as 80 4.00 on the UB04
  • Value codes 08 for LTR amount in first calendar year period, value code 10 for LTR amount in second calendar year period
  • Value code 09 for co-insurance amount in the first calendar year period, value code 11 for co-insurance amount in the second calendar year period

Form Locator 46 - Units of Service

  • Number of units or days of accommodation. Total should match totals of value codes 80-83.

Form locator 47 - Total charges

  • This is the FL in which the provider sums the total charges for the billing period for each revenue code (FL 42); or, if the services require, in addition to the revenue center code, a HCPCS procedure code, where the provider sums the total charges for the billing period for each HCPCS code. The last revenue code entered in FL 42 is "0001" which represents the grand total of all charges billed. The amount for this code, as for all others is entered in FL 47.

Form Locator 50 A-C

  • Medicare must also be listed on the appropriate insurance line, not Noridian

Form Locator 60 A-C

  • Appropriate Medicare Beneficiary Identification (MBI) number for the beneficiary

It is your responsibility to ask about any other applicable insurance. If another insurance is primary over Medicare, provide a copy of any payment or denial from the other insurance with the claim.

Submit a completed hardcopy red and white UB04 form. Noridian will not accept electronic or faxed claims for Part A services. If the claims are not submitted on the red and white UB04 form, they will be returned to you.

Please note: any professional revenue codes should not be billed on the UB04, or the claim will be returned to the provider (RTP) as unprocessable.

Medicare is prohibited by law from paying for services performed by physicians working in federal hospitals.  There are certain exceptions which are explained in IOM 100-04 Chapter 12, section 90.1 - Physicians in Federal Hospitals.

Medical Review and Documentation

  • Emergency services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.
  • Services in Nonparticipating Domestic Hospital Payment may be made for certain Part A inpatient and Part B outpatient hospital services provided in a nonparticipating U.S. hospital where they are necessary to prevent the death or serious impairment of the health of the individual. Because of the threat to the life or health of the individual, the use of the most accessible hospital equipped to furnish such services is necessary.
  • Claims for emergency services must be accompanied by a physician's statement describing the nature of the emergency and stating that the services were necessary to prevent the death, or the serious impairment of, the beneficiary. A statement that an emergency existed is not sufficient. In addition, when inpatient services are involved, the statement must include the date when, in the physicians' judgment, the emergency ceased.

Submit documentation to support:

  • Accessibility:
  • If they come via ambulance, submit the EMS report to help support accessibility
  • Supporting documentation if circumstances do not allow use of closest participating hospital (for example: due to lack of beds available at closest participating hospital, road closures, etc)
  • Does documentation support a specific medical or practical need to use non-participating hospital?
  • Emergency:
  • Ensure documentation submitted includes an assessment by physician or physician extender
  • Planned clinic visits would not support an emergent visit
  • Overall documentation would have to support why non-participating hospital was necessary/emergent: for example- to prevent death or serious impairment of bene

Resources:

Appeals Submission

Claims that are denied with reason code 7MTFD can be appealed.

  • Submit Redetermination request. The request must be received within 120 days from the initial determination (the date of the remittance advice). The request must include, at a minimum, the following
  • Beneficiary name;
  • Medicare number;
  • Specific service(s) and/or items for which the redetermination is being requested;
  • The specific date(s) of the service; and
  • The name of the party or the representative of the party.

Note: Be sure to include documentation supporting the need for the emergency services.

Noridian has 60 days to complete the redetermination. If the redetermination decision is favorable, the claim will be adjusted and the facility will receive a remittance advice. If the redetermination is unfavorable, partially favorable or dismissed the facility will receive a decision letter.

Resources:

Last Updated Feb 19 , 2026