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Claim Submission

Claim Submission

Topic Brief Description

Annual Benefits

Benefit days, Coinsurance, Deductible amounts

Claims Processing Timeliness Interest Rate Interest must be paid on clean claims if payment is not made within 30 days (ceiling period) after date of receipt. Ceiling period is same for both EMC and paper claims

Crossover Claims

The Benefit Coordination & Recovery Center (BCRC) processes all claims crossovers. View details:

Electronic Claim Submission

Connect with EDI regarding electronic claim submissions

Electronic Submission of Medical Documentation (esMD) Medicare's Electronic Submission of Medical Documentation (esMD) pilot project gives some providers a new mechanism for submitting medical documentation to review contractors
HICN Suffixes View definition of suffix in beneficiary Medicare numbers
Incarceration Claim Denials Medicare will generally not pay for medical items and services furnished to a beneficiary who was incarcerated or in custody under a penal statute or rule at time items and services were furnished
Integrated Outpatient Code Editor (IOCE) and Medicare Code Editor (MCE) The IOCE program processes claims for all outpatient institutional providers including hospitals subject to Outpatient Prospective Payment System (OPPS) and Non-OPPS hospitals, such as Critical Access Hospitals (CAHs). The MCE is the inpatient code editor and is used to detect claim errors based on coding listed on UB-04 claims submitted to Medicare

National Correct Coding Initiative (NCCI) Edits

Access National Correct Coding Initiative (NCCI) Edit Files, Medically Unlikely Edit (MUE) Files, Procedure-to-procedure (PTP) Edit Files and Add-on Code Edit Files

Outpatient Coding Questions Providers may address Healthcare Common Procedure Coding System (HCPCS) related inquiries to "Central Office on HCPCS."  Mail or fax
Provider Enrollment, Chain, and Ownership System (PECOS)

If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you must submit an enrollment application to Medicare. You can do this using the Internet-based PECOS or by completing paper enrollment application (CMS-855O)

PWK (Paperwork) PWK (Paperwork) is a segment within 837 Professional and Institutional electronic transactions. The PWK segment provides ‘linkage' between electronic claims and additional documentation which is needed for claims adjudication
Quick Reference Billing Guide

View a compilation of most commonly used coding and billing processes for Medicare Part A claims

Reason Code Guidance View most common claim submission error codes, a description of issue and potential solutions
Returned to Provider (RTP) Help List of common reason codes why claims are Returned to Provider (RTP) for correction

Services Provided Outside the United States

View exceptions to "foreign" exclusion

Social Security Number Removal Initiative (SSNRI) Congress requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new randomly generated Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number on new Medicare cards.

Timely Filing

View how long a provider has to submit a claim based on date of service

UB-04 (CMS-1450) Instructions This link will take you to an external website.

The CMS-1450 form (aka UB-04 at present) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from the ASCA requirement for electronic submission of claims

Submit paper claims to appropriate state address indicated on Mailing Addresses webpage

 

Last Updated Jan 11, 2017