100-04 Medicare Claims Processing Manual: Chapter 2 - Admission and Registration Requirements

Medicare Claims Processing Manual
Chapter 2 - Admission and Registration Requirements
Table of Contents
(Rev. 12423; Issued: 12-20-23)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
Transmittals for Chapter 2
01 - Purpose of Chapter
05 - Definition of Provider and Supplier
10 - General Admission and Registration Rules
10.1 - Medicare beneficiary identifiers
10.1.1 - Changes to Medicare beneficiary identifiers
10.1.2 - Contractor Procedures for Obtaining Missing or Incorrect
Medicare beneficiary identifiers
10.1.3 - Importance of Medicare beneficiary identifiers
10.2 - Prohibition Against Waiver of Health Insurance Benefits as a Condition of
Admission
10.3 - Requiring Prepayment as a Condition of Admission is Prohibited
10.4 - When Prepayment May Be Requested
10.5 - Hospital and Skilled Nursing Facility (SNF) Verification of Prior Hospital
Stay Information for Determining Deductible and Benefit Period Status
10.6 - Hospitals May Require Prepayment for Noncovered Services
10.7 - Compliance With Agreement
10.8 - Request for Payment Should Be Obtained in All Cases as Protective
Application for Hospital Insurance Benefits
10.9 - A/B MAC (A) or (HHH) Requests to Verify Patient’s Medicare beneficiary
identifier
10.10 - A/B MAC (A) or (HHH) Learns Beneficiary is an HMO Enrollee
10.11 - Retroactive Entitlement

10.12 - SNF Verification of Prior Hospital Stay and Transfer Requirements
20 - Obtaining Information to Determine Whether to Bill Medicare or Another Payer
20.1 - Provider Development of Medicare Secondary Payer
30 - Provider/Supplier Obtaining/Verifying the Medicare beneficiary identifier and
Entitlement Status
30.1 - Cross-Reference of Medicare beneficiary identifier
30.2 - Health Insurance (HI) Card
30.3 - Temporary Eligibility Notice
30.4 - Certificate of Social Insurance Award
30.5 - Medicare Summary Notice (MSN)
30.6 - Provider Access to CMS and A/B MAC (A) or (HHH) Eligibility Data
30.6.1 - Reserved
30.6.1.1 - Part A Inquiry (HIQA) Screen Display
30.6.1.2 - Part A Inquiry Reply (HIQAR) Screen Display
30.6.1.3 - Part A Inquiry (HUQA) Data
30.6.1.4 - Part A Inquiry Reply (HUQAR) Data
30.6.1.5 - Health Insurance Query for Home Health Agencies
(HIQH)
30.6.2 - Reserved
30.6.3 - Reserved
30.6.4 - Reserved
30.6.5 - Reserved
30.6.6 - Reserved
30.8 - Reserved
30.10 - Reserved
30.11 - Reserved
30.12 - Reserved
30.13 - Reserved
30.14 - Reserved
30.15 - Reserved
30.16 - Reserved
30.17 - Reserved
30.18 - Reserved

30.19 - Reserved
30.19.1 - Reserved
30.19.2 - Reserved
30.19.3 - Reserved
30.19.4 - Reserved
30.20 - Reserved
30.21 - Requesting Assistance in Resolving Problem Areas in the Inquiry/Inquiry
Response Procedures
30.21.1 - HMO-Related Master File Corrections
30.22 - Provider Problems Obtaining Entitlement Information
50 - Critical Case Procedures - Establishing Entitlement Under Part A and B
60 - Reserved
60.1 - Reserved
60.2 - Reserved
70 - SSO Assistance in Resolving Entitlement Status Problems
90 - Outpatient Hospital Registration Procedures
90.1 - Patient Identification
90.2 - Determining Whom to Bill
90.3 - Source of Admission - Outpatient Hospital
90.4 - Type of Bill
90.5 - Definition of Diagnostic Services
90.6 - Definition of Encounter
100 - Reserved
100.1 - Reserved
110 - Reserved
110.1 - Reserved
120 - Reserved

01 - Purpose of Chapter
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
This chapter describes general requirements with respect to verifying an individual’s
Medicare eligibility and entitlement status for providers, suppliers, A/B MACs (A), (B),
and (HHH), and DME MACs. It also includes general requirements for hospitals for
determining the source admission for use later in the claims process.
05 - Definition of Provider and Supplier
(Rev. 12423; Issued: 12-20-23; Effective: 01-01-24; Implementation: 01-02-24)
This chapter uses the definition of provider and supplier found in 42 CFR 400.202. These
are:
Provider means a hospital, a CAH, a skilled nursing facility, a comprehensive
outpatient rehabilitation facility, a home health agency, or a hospice that has in
effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency,
or a public health agency that has in effect a similar agreement but only to furnish
outpatient physical therapy or speech-language pathology services, or a
community mental health center that has in effect a similar agreement but only to
furnish partial hospitalization or intensive outpatient services.
Supplier means a physician or other practitioner, or an entity other than a
provider that furnishes health care services under Medicare.
Note that while rural health clinics, Federally qualified health centers, and renal dialysis
facilities are suppliers under the regulation, they submit most claims to A/B MACs (A).
10 - General Admission and Registration Rules
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
The following is a general description of requirements and prohibited activities that apply
to admission for inpatient services or registration for other healthcare services.
Upon admission, Prospective Payment System (PPS) hospitals and acute care hospitals in
areas with waivers from PPS are required to give the notice, “An Important Message
from Medicare,” to beneficiaries (available at www.cms.gov/Medicare/Medicare-
General-
Information/BNI/downloads/RevisedImportantMessageFromMedicare05_2007.pdf). The
facility inserts its Quality Improvement Organization’s (QIO) name, address, and phone
number. It provides this notice to each Medicare patient or the patient’s representative.
The CMS does not supply copies of the notice.

Upon admission of a Medicare beneficiary to an institution that bills Medicare, or as soon
thereafter as practical, the provider must verify a patient’s eligibility in order to process
the bill. The provider may obtain this eligibility information directly from the patient or
through the provider’s A/B MAC (A)’s limited Medicare eligibility data. See §30.6. The
provider contacts its A/B MAC (A) to obtain technical instructions regarding how this
access may be implemented along with hardware/software compatibility details.
This information does not represent a definitive eligibility status. If the individual is not
on file, the provider uses the usual admission and billing procedure in effect, independent
of this data access.
Disclosure of CMS eligibility data is restricted under the provisions of the Privacy Act of
1974. This information is confidential, and may be used only for verifying a patient’s
eligibility to benefits under the Medicare program. Penalties for misuse by anyone may
result in being found guilty of a misdemeanor and paying a fine not more than $5,000.
10.1 - Medicare beneficiary identifiers
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
The CMS maintains the electronic records for individuals enrolled in the health insurance
program. The CMS issues health insurance cards where entitlement is established
through the Social Security Administration (SSA), and the Railroad Retirement Board
(RRB) issues health insurance cards where entitlement is established through RRB.
See Chapter 2 of the Medicare General Information, Eligibility, and Entitlement Manual
(Pub. 100-01) for an extended discussion of HI cards and Medicare beneficiary
identifiers.
10.1.1 - Changes to Medicare beneficiary identifier
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.

Changes in an individual’s entitlement to Medicare benefits may result in an individual
being assigned a completely different HICN. For example, an individual not entitled to
monthly benefits (000-00-0000T) marries and becomes entitled to wife’s benefits on her
husband’s account (111-11-1111B). If a claim is submitted under the old HICN, the
Common Working File (CWF) disposition code 51 will notify the A/B MAC (A), (B),
(HHH), or DME MAC (whom we will refer to as the MAC when all are meant) of the
new HICN. The MAC will annotate its records and use the new HICN when submitting
future bills or claims.
10.1.2 - Contractor Procedures for Obtaining Missing or Incorrect
Medicare beneficiary identifier s
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
Upon receipt of a claim or other paper on which the Medicare beneficiary identifier is
omitted, incomplete, inconsistent, or obviously incorrect, the MAC submits the claim to
CWF with the best information it has available. Depending on the CWF reply, the MAC
follows the instructions in Chapter 27 for handling various disposition codes, trailers, and
error codes.
10.1.3 - Importance of Medicare beneficiary identifier s
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
The Medicare beneficiary identifier is used in Medicare records to identify the
beneficiary. The provider or supplier obtains this number before billing. See §30 below
for a description of appropriate processes for obtaining the Medicare beneficiary
identifier.
10.2 - Prohibition Against Waiver of Health Insurance Benefits as a
Condition of Admission
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)

Providers may not require, as a condition of admission or treatment, that a patient agree
to waive the right to have services paid for under Medicare. Requiring such a “waiver” is
inconsistent with the agreement with CMS, and the “waiver” is not binding upon the
patient. Providers have agreed not to charge an individual (except for specified
deductible and coinsurance amounts) for services for which such individual is entitled to
have payment made or for which he/she would be entitled if the provider complied with
the procedural and other requirements of the program. Further, under this provision, the
provider must refund any amounts incorrectly collected.
Where a patient who has signed such a waiver, nevertheless, requests payment under the
program, the provider must bill the A/B MAC (A) and refund any payments made by the
patient, or on the patient’s behalf, in excess of permissible charges.
10.3 - Requiring Prepayment as a Condition of Admission is Prohibited
(Rev. 1, 10-01-03)
HO-303, SNF-317
Providers must not require advance payment of the inpatient deductible or coinsurance as
a condition of admission. Additionally, providers may not require that the beneficiary
prepay any Part B charges as a condition of admission, except where prepayment from
non-Medicare patients is required. In such cases, only the deductible and coinsurance
may be collected. Where the patient does not have Part B entitlement, the provider will
follow the rules in §10.6.
10.4 - When Prepayment May Be Requested
(Rev. 1, 10-01-03)
HO-303.2
The provider may collect deductible or coinsurance amounts only where it appears that
the patient will owe deductible or coinsurance amounts and where it is routine and
customary policy to request similar prepayment from non-Medicare patients with similar
benefits that leave patients responsible for a part of the cost of their hospital services. In
admitting or registering patients, the provider must ascertain whether beneficiaries have
medical insurance coverage. Where beneficiaries have medical insurance coverage, the
provider asks the beneficiary if he/she has a Medicare Summary Notice (MSN) showing
his/her deductible status. If a beneficiary shows that the Part B deductible is met, the
provider will not request or require prepayment of the deductible.
Except in rare cases where prepayment may be required, any request for payment must be
made as a request and without undue pressure. The beneficiary (and the beneficiary’s
family) must not be given cause to fear that admission or treatment will be denied for
failure to make the advance payment.
Providers must insure that the admitting office personnel are informed and kept fully
aware of the policy on prepayment. For this purpose, and for the benefit of the provider

and the public, it is desirable that a notice be posted prominently in the admitting office
or lobby to the effect that no patient will be refused admission for inability to make an
advance payment or deposit if Medicare is expected to pay the hospital costs.
10.5 - Hospital and Skilled Nursing Facility (SNF) Verification of Prior
Hospital Stay Information for Determining Deductible and Benefit
Period Status
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
If it has been determined that Medicare is the primary payer, the hospital or SNF must
determine if the patient has been an inpatient in any hospital or SNF, including swing bed
stays, during the prior 60 days. If so, the hospital or SNF must determine the admission
and discharge dates and the number of days of hospitalization or skilled nursing (as
applicable) the patient used in the current benefit period. The admission and discharge
dates must be reported on the claim, and the number of days of hospitalization or skilled
nursing (as applicable) must be used to calculate the hospital insurance copayment and
the number of days remaining in the benefit period.
If the patient indicates he/she was not an inpatient within the last 60 days, the hospital
applies the inpatient deductible to the current stay if it is a covered hospital admission.
The A/B MAC (A) determines the accuracy of the claim data after receipt of the claim.
The remittance advice received from the A/B MAC (A) reflects the amount of deductible
(hospital claims) and coinsurance (hospital and SNF claims) applied. If this amount is
different from what was billed, the hospital/SNF must correct the records accordingly.
10.6 - Hospitals May Require Prepayment for Noncovered Services
(Rev. 1, 10-01-03)
HO-303.3
With regard to noncovered services (e.g., personal comfort items, a private duty nurse),
the hospital may deny such services for which the beneficiary has not paid or offered
satisfactory assurance of payment if that is the hospital’s practice with nonbeneficiary
patients. For example, a private room or TV set need not be furnished to a patient who
requests it but is unable to prepay or offer the assurance of payment which is usually
required.
Where the individual has exhausted his/her covered inpatient hospital benefits, or cannot
supply satisfactory evidence of entitlement under Part A, providers are free to apply to
such persons the hospital’s usual policy with respect to requiring prepayment or other
assurance of payment where the patient has no insurance. In addition, for the
beneficiaries receiving covered inpatient services who are not enrolled for medical
insurance (Part B), the hospital can apply its usual policy on prepayment or assurance of
payment with regard to services of salaried physicians provided.
10.7 - Compliance With Agreement

(Rev. 1, 10-01-03)
HO-303.4
Providers must conform to the policy set forth in this instruction. Noncompliance will be
considered in determining whether the provider is honoring its agreement, under which it
may not charge for services for which payment may be made under the Medicare
program.
10.8 - Request for Payment Should Be Obtained in All Cases as
Protective Application for Hospital Insurance Benefits
(Rev. 1, 10-01-03)
HO-266, HO-307, SNF-407
To become entitled to HI benefits, an individual must not only be eligible, but must also,
prior to death, have filed an application for such benefits (or for monthly social security
benefits). Even though the individual meets all eligibility requirements, if the individual
does not file the necessary application before death, the individual cannot become
entitled, and no payment can be made for hospital services. The provider should obtain a
written request for title XVIII payment, filed by or on behalf of a patient, upon admission
as described in Chapter 1.
Occasionally, a Medicare eligible patient age 65 or over who is admitted to a hospital,
has never applied for benefits. A request for payment will protect the eligible patient, the
patient’s estate, and the provider against the possibility that timely application will not be
filed. If the patient refuses to sign the request, the provider will respect the patient’s
wishes. The provider may then require the patient to pay or give assurance of payment in
accordance with customary practice for non-beneficiaries. If the patient cannot sign, and
is not accompanied by anyone who can sign on the patient’s behalf, an authorized
provider official may execute the request for payment on the patient’s behalf. The
admission record containing the request should contain the patient’s name and be signed
and dated as of the signature date.
Where the Social Security Office (SSO), upon the provider’s inquiry for a claim number,
finds that an apparently eligible inpatient has not applied for benefits; and that the filing
date established by the written request might permit payment (not otherwise possible) for
the individual’s inpatient services; the SSO will ask the provider for a photocopy of the
admission record containing the signed request. The SSO may ask the provider to file a
prescribed application for benefits on behalf of the patient who is incompetent if there is
no other qualified applicant.
In the case of a deceased patient, who prior to death signed a document that protected the
filing date, a provider may apply on behalf of the patient if no other qualified applicant
applies within six months of the date of notice of the need for application. However,
where a qualified survivor or representative of the estate refuses to file and states in
writing that his/her refusal is based upon the fact that filing would be detrimental to the

deceased’s estate, hospital insurance entitlement cannot be established and payment
cannot be made for services.
10.9 - A/B MAC (A), (B), or (HHH), or DME MAC Requests to Verify
Patient’s Medicare beneficiary identifier
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
Where the name and Medicare beneficiary identifier information on a claim does not
match the CMS central record, the A/B MAC (A), (B), or (HHH), or DME MAC will
return the claim to the provider and request the provider to verify the information.
The provider will compare the name and number on the claim with that on provider
records. If the information submitted was incorrect, the provider will return the claim to
the MAC with the corrected information.
If, however, the information in the provider’s records identifying the patient is the same
as the information submitted on the claim, the provider will contact the SSO for
assistance.
10.10 - A/B MAC (A), (B), or (HHH) or DME MAC Learns Beneficiary
is an HMO Enrollee
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
If the A/B MAC (A), (B), or (HHH), or DME MAC determines from its records or its
query to CMS that a patient is an HMO enrollee, the MAC will return the claim to the
provider with instructions to request payment from the HMO for payment, if appropriate.
10.11 - Retroactive Entitlement
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
When an application for social security benefits is filed by a person 65 years of age or
older, the person may inform the SSO that he/she received hospital services in the
retroactive period of up to six months for which he/she may be entitled to benefits. In
these cases, the provider may bill for covered retroactive services but must verify the
patient’s eligibility through the A/B MAC (A), (B), or (HHH), or DME MAC before

billing. If the patient paid, the provider must refund the appropriate amount to the
patient.
10.12 - SNF Verification of Prior Hospital Stay and Transfer
Requirements
(Rev. 1, 10-01-03)
SNF-414
SNFs must verify that the beneficiary was discharged from a hospital with a transfer
agreement with the SNF and that:
a. 	The date of discharge is on or after the first day of the month in which the
beneficiary became entitled to Medicare;
b. 	The hospital stay was at least three calendar days in duration (hospital days to
which waiver of liability was applied cannot be used to satisfy the 3-day
requirement); and
c. 	The 3-day qualifying stay was within 30 days of the SNF admission, unless the
rules for exception apply.
The hospital usually sends the SNF a patient transfer form or other record in accordance
with the transfer agreement. The dates of the hospital stay are required on the claim.
For more information on the above criteria, see Chapter 8 of the Medicare Benefit Policy
Manual.
20 - Obtaining Information to Determine Whether to Bill Medicare or
Another Payer
(Rev. 1, 10-01-03)
HO-300, SNF-401
The provider must ascertain whether the patient is a member of a Medicare + Choice
organization (M+CO). If the patient is a member of an M+CO, the provider must contact
the M+CO specified by the patient or identified on the patient’s membership card, so the
provider may determine whether to submit the claim to the M+CO.
If the patient indicates that he/she is not a member of an M+CO, the provider, in order to
determine whom to bill, develops for situations where Medicare is the secondary payer
by obtaining answers to the “Admission Questions to Ask Medicare Beneficiaries”
contained in Chapter 3 of the Medicare Secondary Payer Manual. If another insurer is
identified as primary to Medicare, the provider follows the procedures in the Medicare
Secondary Payer (MSP) Manual.
20.1 - Provider Development of Medicare Secondary Payer
(Rev. 1, 10-01-03)

HO-301, SNF-401, A-03-031
Medicare is the secondary payer under certain circumstances. See Medicare Secondary
Payer (MSP) Manual, Chapter 1, for related instructions.
30 - Provider/Supplier Obtaining/Verifying the Medicare beneficiary
identifier and Entitlement Status
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
It is important that the patient’s Medicare beneficiary identifier be obtained and
accurately recorded because the claim cannot be processed if the Medicare beneficiary
identifier is missing or incorrect. A social security number is not sufficient.
When a patient 65 years of age or over, or a younger patient who possibly has entitlement
to Medicare as a disability beneficiary or under the provisions for coverage of persons
needing a kidney transplantation or dialysis, is admitted or registered for services, the
provider asks for the health insurance card, Temporary Notice of Medicare Eligibility, or
other notice the patient has received from CMS or an A/B MAC (A), (B), (HHH), or
DME MAC which shows the Medicare beneficiary identifier. If a patient or prospective
patient is within three months of age 65, or is disabled or has ESRD, and has not applied
for HI entitlement, the provider advises the patient to contact the SSO, or to have
someone do so on the patient’s behalf. The provider may arrange with the SSO to
routinely bring such cases to the SSO’s attention.
This requirement also applies to inpatient services for which no payment is due because
providers are required to submit inpatient claims even when benefits are exhausted or are
not payable for some reason. The CMS requires this data to record necessary benefit
information on CMS records. Where the patient refuses to request payment and refuses
to furnish information about his/her Medicare beneficiary identifier, the provider
documents the records accordingly and attempts to get the Medicare beneficiary identifier
from the SSO.
30.1 - Cross-Reference of Medicare Beneficiary Identifier
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and

the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
If a beneficiary’s entitlement to Medicare has been transferred from one Medicare
beneficiary identifier to another, the CWF will cross-reference the old number to the new
number. If there has been utilization of benefits under each number, all data will be
combined under the new number.
A. Disposition Code 51
1. If, after submitting the admission notice or Part B claim to CMS, the MAC receives
a disposition code of 51 with trailer code 01 containing a possible Medicare
beneficiary identifier, the MAC investigates the new Medicare beneficiary
identifier, and if it believes the new Medicare beneficiary identifier is correct, the
MAC resubmits the claim under the new Medicare beneficiary identifier. CWF
responds with an appropriate disposition code and any associated trailers for
processing the claim.
2. If the MAC receives a disposition code of 51 without trailer code 01, or after
investigation determines the Medicare beneficiary identifier in the 01 trailer is
incorrect, it denies the claim using the following message:
Payment cannot be made for the services you received from (name
of provider) because we have no record of your Medicare
beneficiary identifier. Please write your correct number on the
claim and resubmit the claim to (name of provider). If you think
the number is right, check with your local Social Security Office.
B. Disposition Code 55
If CWF returns disposition code 55 and trailer code 08 containing an error code of 5052,
indicating a mismatch in the beneficiary’s personal characteristics, CWF will also return
to the MAC what it believes to be the proper information on trailer code 10. The header
portion of the response also contains the corrected sex and birth date, if applicable, of the
beneficiary.
The MAC investigates the information provided, corrects the information on the claim,
and resubmits it to CWF. If the MAC continues to receive a code 55, it contacts the Host
through locally established procedures. See Chapter 27.
30.2 - Health Insurance (HI) Card
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare

beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
As part of health insurance electronic data processing, HI cards are issued by CMS (or by
the RRB where railroad retirement beneficiaries are involved) to individuals who have
established entitlement to health insurance. (See Chapter 2 of the Medicare General
Information, Eligibility, and Entitlement Manual.) The health insurance card is used to
identify the individual as being entitled and serves as a source of information required to
process Medicare claims or bills. The health insurance card displays the beneficiary’s
name, sex, Medicare beneficiary identifier, and effective date of entitlement to hospital
insurance and/or medical insurance.
If any MAC receives an inquiry about replacing a lost or destroyed HI card, it informs the
inquirer to get in touch with the SSO nearest the inquirer’s address for assistance. SSO
addresses are generally listed in local telephone directories under “Social Security
Administration.”
A health insurance card is acceptable without a signature, but the provider will ask the
patient to sign it.
30.3 - Temporary Eligibility Notice
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
The SSO may issue a temporary health insurance eligibility notice, pending the issuance
of a health insurance card, when the beneficiary is in need of immediate medical services.
The provider may obtain the patient’s name and Medicare beneficiary identifier from the
temporary eligibility notice. See Chapter 2 of the Medicare General Information,
Eligibility, and Entitlement Manual for an example of the temporary notice.
For claims processed by the A/B MAC (B) or DME MAC, the individual, the
individual’s physician, or other supplier must show the Medicare beneficiary identifier on
the request for Medicare payment and on other related bills and documents. Because
Health Insurance records are maintained by the individual’s Medicare beneficiary
identifier, the Medicare beneficiary identifier must be used on all communications.
claim number, the claim number must be used on all communications.

30.4 - Certificate of Social Insurance Award
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
Health insurance beneficiaries receive a Certificate of Social Insurance Award, SSA-30,
showing the Medicare beneficiary identifier, dates of entitlement to Part A and/or Part B
benefits, and the following statement:
This notice may be used if Medicare services are needed before you receive
your health insurance card.
30.5 - Medicare Summary Notice (MSN)
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
If patients cannot furnish their health insurance cards when admitted, they may have a
MSN form showing the Medicare beneficiary identifier. A notice is mailed to a
beneficiary shortly after Part A or Part B benefits have been paid on the beneficiary’s
behalf. Deductible status is also shown on these forms.
30.6 - Provider Access to CMS and A/B MAC (A) or (HHH) Eligibility
Data
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
The A/B MAC (A) or (HHH) will allow only Medicare certified providers as defined in
§§1861 and 1866(e) of the Social Security Act (the Act) and their billing agents
automated access to beneficiary eligibility data. Disclosure of CWF eligibility data is

restricted under provisions of the Privacy Act of 1974, 5 U.S.C §552a. Under limited
circumstances, the Privacy Act permits CMS to disclose information without consent of
the individual. One circumstance is for “routine uses,” that is, disclosure for purposes
that are compatible with the purpose for which CMS collects the information. In the case
of this provider access, a routine use exists which permits release of data to providers or
their authorized billing agents for the purpose of verifying a patient’s eligibility for
benefits under the Medicare program. The use of the data by a provider in preparing
claims for hospital-based physicians would be an example of unauthorized use because
the physicians are not Medicare providers as defined in the Act.
A/B MACs (A) or (HHH) will adjust their systems to accept the revised standard
HIQA/HUQA records from the CMS CWF. The standard data elements to be made
available to providers are listed below:
• 	Medicare beneficiary identifier;
• 	Beneficiary:
o 	Last name (first six positions)/first initial;
o 	Date of birth;
o 	Sex;
o 	Date of death;
o 	Lifetime reserve days remaining;
o 	Lifetime psychiatric days remaining (requesting hospital must use a
psychiatric provider number to obtain this data);
o 	Cross reference Medicare beneficiary identifier;
o 	Current and prior A and B entitlements, with start and stop dates for Part A,
Part B, ESRD, HMO, and hospice; and
o 	Spell of illness (applicable spell based on the date entered by the provider and
the next most recent spell):
• 	Hospital full days remaining;
• 	Hospital coinsurance days remaining;
• 	SNF full days remaining;
• 	SNF coinsurance days remaining;

• 	Part A cash deductible remaining to be met;
• 	Date of earliest billing action for indicated spell-of-illness;
• 	Date of latest billing action for indicated spell-of-illness;
• 	Blood deductible (combined annual Part A and B remaining to be
met for applicable year entered by provider);
• 	Part B trailer year (applicable year based on date entered by
provider);
• 	Part B cash deductible;
• 	Physical therapy/speech-language pathology limit (physical
therapy and speech-language pathology are applicable to physical
therapy limit);
• 	Occupational therapy limit;
• 	Hospice data (applicable periods based on the date entered by the
provider and the next most recent period);
• 	ESRD indicator (shows beneficiary is currently entitled);
• 	REP payee indicator;
• 	MSP indicator;
• 	Home Health Benefit Period:
o 	Part A visits remaining;
o 	Part B visits applied;
o 	Date of earliest billing action for home health benefit period;
o 	Date of latest billing action for home health benefit period.
• 	HMO information (applicable periods based on date entered by the
provider):
o 	Name;
o 	Identification number;

o 	ZIP Code;
o 	Option code;
o 	Start date;
o 	Termination date;
o 	Pap smear screening risk indicator, professional date, and
technical date;
o 	Mammography screening risk indicator (applicable to
screening services prior to January 1, 1998), professional date,
and technical date;
o 	Colorectal screening (no risk indicator); procedure code,
professional date, and technical date;
o 	Pelvic screening risk indicator and professional date;
o 	Pneumococcal pneumonia vaccine (PPV) date;
o 	Influenza virus vaccine date; and
o 	Hepatitis B vaccine date.
See Chapter 10 of this manual for a complete discussion of the HIQH (Health Insurance
Query for Home Health Agencies).
The A/B MAC (A) will make sure that psychiatric information is not being made
available to all hospitals. This information is to be made available only to psychiatric
hospitals or hospitals that furnish inpatient psychiatric hospital services.
Providers may use direct entry terminals or dial-up terminals to inquire about beneficiary
eligibility utilization and deductible status. The A/B MAC (A) must use either the HIQA
screen display (see §30.6.1.1) or create its own Customer Information Control System
(CICS) screens from the HUQA data records (see §§30.6.1.2 and 30.6.1.3). Providers
may not have access to any other CWF records, e.g., the health insurance master record
(HIMR). The data must be from CWF. The A/B MAC (A) will not substitute local
history.
30.6.1 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)

30.6.1.1 - Part A Inquiry (HIQA) Screen Display
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
All the data elements are explained in full for proper use. A/B MACs (A) or (HHH)
should access this screen to transmit data to their providers and suppliers when supplying
data for §30.6.1.2.
30.6.1.2 - Part A Inquiry Reply (HIQAR) Screen Display
(Rev. 1, 10-01-03)
A3-3508.4
This screen format can be used to pass beneficiary entitlement and utilization data to the
provider. It is described in the CWF Documentation, Chapter VII, Section H, pages 1
through 24. Refer to the CWF Documentation when providing utilization data to the
provider.
30.6.1.3 - Part A Inquiry (HUQA) Data
(Rev. 1, 10-01-03)
A3-3508.5
This transaction may be used to obtain the HUQA dataset. (See §30.6.) Also, refer to
Chapter II of the CSC maintained CWF Documentation.
30.6.1.4 - Part A Inquiry Reply (HUQAR) Data
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
This response can be used to create the A/B MAC (A)’s or (HHH)’s own screens to
return beneficiary eligibility and utilization data to providers.
30.6.1.5 - Health Insurance Query for Home Health Agencies (HIQH)
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
This transaction, which is available through A/B MAC (HHH) remote access, is used by
HHAs to ascertain whether an episode has been opened for a given beneficiary by
another provider (who is the primary HHA) and to track episodes for beneficiaries for
whom the inquiring HHA is the primary HHA.
30.6.2 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)

30.6.3 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.6.4 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.6.5 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.6.6 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.8 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.10 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.11 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.12 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.13 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.14 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.15 - Reserved

(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.16 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.17 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.18 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.19 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.19.1 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.19.2 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.19.3 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.19.4 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.20 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
30.21 - Requesting Assistance in Resolving Problem Areas in the
Inquiry/Inquiry Response Procedures
(Rev. 1, 10-01-03)
A3-3523, 3-6008
See §70.

30.21.1 - HMO-Related Master File Corrections
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
The A/B MAC (A), (B), or (HHH), or DME MAC will fully document and send to the
HMO inquiries concerning problems with HMO data on the HI Master. The HMO will
resolve the problem and advise the contractor of the results.
30.22 - Provider Problems Obtaining Entitlement Information
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
If after application of the above procedures, the provider encounters significant problems
in obtaining information regarding Medicare entitlement or benefits in order to accurately
prepare bills, the provider should contact the A/B MAC (A), (B), or (HHH), or DME
MAC for assistance. However, these requests should be on a non-routine basis. The
MAC will assist providers in obtaining entitlement information. The MAC may
temporarily refuse assistance if a pattern of abuse is discovered. Situations that may
require MAC assistance are:
• 	When the patient dies following admission. It may be necessary to file timely
with an estate;
• 	When the patient is not in a physical or mental condition to discuss his/her
entitlement, and no other person with knowledge of the patient’s affairs is
available;
• 	When the provider has reason to believe the beneficiary may need lifetime reserve
days, and his/her signature must be obtained if the available lifetime reserve days
are not to be used for this admission and other financial arrangements must be
made;
• 	When it is suspected that the beneficiary may have exhausted his/her Medicare
benefits, and timely confirmation is needed in order to file for possible
supplemental benefits; and
• 	When the patient has experienced repeated admissions during the same spell of
illness, and determining available benefits for the beneficiary is difficult.
50 - Critical Case Procedures - Establishing Entitlement Under Part A
and B
(Rev. 1, 10-01-03)
See Chapter 27.

60 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
60.1 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
60.2 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16).
70 - SSO Assistance in Resolving Entitlement Status Problems
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
A. Social Security Office (SSO) Assistance
The A/B MAC (A), (B), or (HHH), or DME MAC directs initial requests for assistance to
the SSO if the problem is caused by difficulties in determining the beneficiary’s correct
entitlement status. Examples of situations that may require SSO assistance are:
• 	Problems involving Railroad Retirement Board (RRB) jurisdiction;
• 	Evidence that a beneficiary has utilization under more than one Medicare
beneficiary identifier but there is no awareness of any cross-reference action taken
by CMS; or
• 	The beneficiary’s name, address, sex code, date of birth, or date of death is
incorrect on the HI master record.
In the event the SSO is unable to resolve the entitlement problem (e.g., cross referencing
of HI records), the MAC requests assistance from the RO.
90 - Outpatient Hospital Registration Procedures
(Rev. 1, 10-01-03)
HO-350

90.1 - Patient Identification
(Rev. 4247, Issued: 03-01-19, Effective: 04-01-19, Implementation: 04-01 -19)
The term Medicare beneficiary identifier (Mbi) is a general term describing a
beneficiary's Medicare identification number. For purposes of this manual, Medicare
beneficiary identifier references both the Health Insurance Claim Number (HICN) and
the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition
period and after for certain business areas that will continue to use the HICN as part of
their processes.
Upon registration of a Medicare beneficiary, or as soon thereafter as practical, the
hospital will ask the patient for his/her health insurance card to obtain the Medicare
beneficiary identifier. If the patient is unable to provide it, the hospital will contact the
SSO for assistance.
90.2 - Determining Whom to Bill
(Rev. 1, 10-01-03)
HO-350.B
The procedures for determining whether another payer exists are the same for outpatient
situations as for inpatient. Therefore, the hospital will follow §20 for developing other
coverage.
90.3 - Source of Admission - Outpatient Hospital
(Rev. 1472, Issued: 03-06-08, Effective: 05-23-07, Implementation: 04-07-08)
The hospital’s registration process must distinguish whether the referral source for this
registration/admission is from:
• 	Its own inpatient hospital;
• 	An encounter in another hospital (see §90.6 for definition of encounter); or
• 	Any other source - See chapter 25.
Hospitals must determine the appropriate source of admission from internal records or by
asking the patient who referred him/her, and whether the referral took place as a result of
an encounter in the servicing hospital, another hospital, or elsewhere.
The following coding must be used on the outpatient claim. Therefore
admission/registration processes must obtain the information.
1. 	Physician Referral - The patient was referred to this facility for outpatient or
referenced diagnostic services by his/her personal physician, or the patient
independently requested outpatient services (self-referral).

2. 	Clinic Referral - The patient was referred to this facility for outpatient or
referenced diagnostic services by this facility’s clinic or other outpatient
department physician.
3. 	HMO Referral - The patient was referred to this facility for outpatient or
referenced diagnostic services by an HMO physician.
4. 	Transfer from a Hospital - The patient was referred to this facility for outpatient
or referenced diagnostic services by a physician of another acute care facility.
5. 	Transfer from a SNF - The patient was referred to this facility for outpatient or
referenced diagnostic services by a physician of the SNF where the patient is an
inpatient.
6. 	Transfer from Another Health Care Facility - The patient was referred to this
facility for outpatient or referenced diagnostic services by a physician of another
health care facility where the patient is an inpatient.
7. 	Emergency Room - The patient was referred to this facility for outpatient or
referenced diagnostic services by this facility’s emergency room physician.
8. 	Court/Law Enforcement -The patient was referred to this facility for outpatient or
referenced diagnostic services upon the direction of a court of law, or upon the
request of a law enforcement agency representative.
9. 	Information not available.
10. Transfer from a CAH - The patient was referred to this facility for outpatient or
referenced diagnostic services by (a physician of) the CAH were the patient is an
inpatient.
The hospital must determine the proper source of admission code based on the patient’s
response and/or any other information the hospital may have available from its
preregistration records or scheduling data. The hospital must enter the proper source of
admission code on the claim.
NOTE: Information regarding the form locator number that corresponds to the source of
admission code and a table to crosswalk its CMS-1450 form locator to the 837
transaction is found in Chapter 25.
If the patient was referred for services by a physician at:
• 	This hospital, the hospital enters codes 2 or 7;
• 	Another hospital, the hospital enters code 4; or
• 	Some other source, the hospital enters codes 1, 3, 5, 6, 8, 9, or A, as appropriate.

If the hospital is sure the admission source is not from its hospital or another hospital but
cannot determine which of the codes apply, the hospital will enter code 1 on Medicare
claims. However, incorrect reporting where services were referred by staff at its own
hospital or another hospital (codes 2, 4, or 7 are applicable) is considered program abuse
and subject to applicable sanctions.
90.4 - Type of Bill
(Rev. 2971, Issued: 05-23-14, Effective: 07-01-14, Implementation, 07-07-14)
To properly bill, hospitals other than CAHs assign type of bill (TOB) 13X to all bills for
outpatient hospital services and TOB 14X for non-patient (referred) laboratory
specimens. A non-patient is defined as a beneficiary that is neither an inpatient nor an
outpatient of a hospital, but that has a specimen that is submitted for analysis to a hospital
and the beneficiary is not physically present at the hospital.
TOB 14X should only be billed for non-patient lab specimens, which are paid under the
clinical laboratory fee schedule at the lesser of the actual charge, the fee schedule
amount, or the National Limitation Amount (NLA), (including CAHs and MD Waiver
hospitals). Part B deductible and coinsurance do not apply for laboratory tests payable on
the laboratory fee schedule.
TOB 14X should no longer be used for referred diagnostic services other than laboratory
services.
CAHs should bill TOB 85X for outpatient services (including outpatient labs), and TOB
14X for non-patient laboratory specimen tests.
90.5 - Definition of Diagnostic Services
(Rev. 1, 10-01-03)
HO-350.E
A service is “diagnostic” if it is an examination or procedure to which the patient is
subjected, or which is performed on materials derived from a hospital outpatient to obtain
information to aid in the assessment of a medical condition or the identification of a
disease. Among these examinations and tests are diagnostic laboratory services such as
hematology and chemistry, diagnostic x-rays, isotope studies, EKGs, pulmonary function
tests, psychological tests, and other tests given to determine the nature and severity of an
ailment or injury. Hospitals may determine whether services are diagnostic from their
internal systems as appropriate.
90.6 - Definition of Encounter
(Rev. 1, 10-01-03)
HO-350F
The term “encounter” means a direct personal contact in the hospital between a patient
and a physician, or other person who is authorized by State law and, if applicable, by

hospital staff bylaws to order or furnish services for diagnosis or treatment of the patient.
Direct personal contact does not include telephone contacts between a patient and
physician. Nor is the compensation arrangement between the physician and the hospital
relevant to whether an encounter has occurred. Patients will be treated as hospital
outpatients for purposes of billing for certain diagnostic services that are ordered during
or as a result of an encounter that occurred while such patients are in an outpatient status
at the hospital. If a Medicare outpatient is referred to another provider or supplier for
further diagnostic testing or other diagnostic services as a result of an encounter that
occurs in this hospital, the hospital is responsible for arranging with the other entity for
the furnishing of services. Hospitals are not required to verify that all ordered services
are furnished but only to assure that, when it is necessary to refer a patient to an outside
entity, the referral is made to a provider or supplier with which the referring hospital an
arrangement. This requirement is necessary to assure that billing for services that are
furnished is processed through the servicing hospital.
When a patient has follow-up visits with a physician in the hospital following an initial
encounter, each subsequent visit to the physician will be treated as a separate encounter
for billing.
100 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
100.1 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
110 - ESRD Method Selection
(Rev. 1, 10-01-03)
See chapter 8, for instructions for completing the ESRD Method Selection Form.
110.1 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)
120 - Reserved
(Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC
Implementation: 02-16-16; ASC X12: 02-16-16)

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date 	CR#
R12423CP 12/20/2023 	Enforcing Billing Requirements for
Intensive Outpatient Program (IOP)
Services with New Condition Code 92
01/02/2024 	13222
R4247CP 	03/01/2019 	Update to Publication 100-04
Chapters 2, 6, and 18 to Provide
Language-Only Changes for the New
Medicare Card Project
04/01/2019 	11155
R3441CP 	01/15/2016 	Update to Pub. 100-04, Chapter 02
Admission and Registration
Requirements, for Provider
Verification of Beneficiary Eligibility
and Entitlement
02/16/2016 	9457
R2971CP 	05/23/2014 	July 2014 Update of the Hospital
Outpatient Prospective Payment
System (OPPS)
07/07/2014 	8776
R1472CP 	03/06/2008 	Update of Institutional Claims
References
04/07/2008 	5893
R1421CP 	01/25/2008 	Update of Institutional Claims
References – Rescinded and Replaced
by Transmittal 1472
04/07/2008 	5893
R1257CP 	05/25/2007 	Important Message From Medicare
(IM) and Expedited Determination
Procedures for Hospital Discharges
07/02/2007 	5622
R980CP 	06/14/2006 	Changes Conforming to CR 3648
Instructions for Therapy Services -
Replaces Rev. 941
10/02/2006 	4014
R941CP 	05/05/2006 	Changes Conforming to CR 3648
Instructions for Therapy Services
10/02/2006 	4014
R851CP 	02/10/2006 	Revisions to Instructions for
Contractors Other Than the Religious
Nonmedical Health Care Institutions
Specialty Contractor Regarding
Claims for Beneficiaries with RNCHI
Elections
05/11/2006 	4218

R795CP 	12/30/2005 	Redefined Type of Bill 14X For Non-
Patient Laboratory Specimens-CR
3835 Manualization
04/03/2006 	4208
R001CP 	10/01/2003 	Initial Publication of Manual 	NA 	NA
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