100-04 Medicare Claims Processing Manual: Chapter 1 Crosswalk

Medicare Claims Processing Manual
Chapter 1 - General Billing Requirements
Crosswalk
Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	01 	Foreword
1 	10 	Jurisdiction for Claims
1 	10.1 	B3-3100 	Carrier Jurisdiction of Requests for Payment
1 	10.1.1 	B3-3100.1,
B3-3101,
B4-2010
partial,
B3-4267,
R1813B3
Area Carrier Physician's Services
1 	10.1.2 	Physician, Supplier, and Group Practice Billing for Multiple
Locations
1 	10.1.3 	B3-3100.6,
R1813B3
Exceptions to Provider Billing Local Carrier
1 	10.1.4 	B3-2312 	Services Received by Medicare Beneficiaries Outside the United
States
1 	10.1.4.1 	B3-2312-
2312.2
Physician and Ambulance Services Furnished in Connection With
Covered Foreign Inpatient Hospital Services

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	10.1.4.2 	B3-2312.3 	Carriers Designated to Process Foreign Claims
1 	10.1.4.3 	B3-2312.4 	Source of Part B Claims
1 	10.1.4.4 	B3-2312.5 	Medicare Approved Charges for Services Rendered in Canada or
Mexico
1 	10.1.4.5 	B3-2312.6 	Appeals of Denied Charges for Physicians and Ambulance
Services in Connection With Foreign Hospitalization
1 	10.1.4.6 	B3-2312.7 	Claims for Services Furnished in Canada and Mexico to Qualified
Railroad Retirement Beneficiaries
1 	10.1.4.7 	B3-2020.1 	Shipboard Services Billed to the Carrier
1 	10.1.5 	B3-3102,
B3-3116
Domestic Claims Processing Jurisdictions
1 	10.1.5.1 	B3-3116 	Suppliers of Durable Medical Equipment, Prosthetics, Orthotics,
Supplies, Parental and Enteral Nutrition (PEN)
1 	10.1.5.2 	Supplier of Portable X-Ray, EKG or Similar Portable Services
1 	10.1.5.3 	Ambulance Services Submitted to Carriers
1 	10.1.5.4 	Independent Laboratories
1 	10.1.5.4.1 	Cases Involving Referral Laboratory Services
1 	10.1.6 	B3-3103 	Railroad Retirement Beneficiary Carrier

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	10.1.7 	B3-3104,
B3-3060 for
buy-in
definition
Welfare Carriers
1 	10.1.8 	B3-3105 	United Mine Workers of America (UMWA)
1 	10.1.9 	B3-3110 	Disposition of Misdirected Claims
1 	10.1.9.1 	Area Carrier to Another Area Carrier
1 	10.1.9.2 	B3-3110 	Area Carrier to RRB-Named Carrier
1 	10.1.9.3 	RRB-Named Carrier to Area Carrier
1 	10.1.9.4 	Area Carrier or RRB-Named Carrier to Welfare Carrier
1 	10.1.9.5 	Protests Concerning Transfer of Requests for Payment to Carrier
or Intermediary
1 	10.1.9.6 	B3-3110.1 	Transfer of Claims Material Between Carrier and Intermediary
1 	10.1.9.6.1 	B3-3110.2 	Signature Requirements for Carriers and Intermediaries
1 	10.2 	Intermediary Jurisdiction of Requests for Payment
1 	10.2.1 	Intermediary Payment for Emergency and Foreign Hospital
Services
1 	10.3 	B3-3115 	Payments Under Part B for Services Furnished by Suppliers of
Services to Patients of a Provider
1 	20 	A2-2807.A,
A3 3600 4
OPT-122 	Provider Election of Intermediary

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
A3-3600.4
1 	20.1 	A2-2807.B 	Intermediary Service to HHAs and Hospices
1 	20.2 	A2-2807.C 	Provider Change of Ownership (CHOW)
1 	20.3 	A2-2807.D 	Multi-State Provider Chains Billing Intermediaries
1 	20.4 	A2.2808 	The Process for a Provider to Change an Intermediary
1 	20.5 	A2.2809 	Intermediary Relationships With Providers Serviced by Another
Intermediary
1 	20.5.1 	Solicitation of a Provider to Secure a Change of Intermediary
1 	20.5.2 	Communications
1 	30 	A2-2810 	Provider Participation
1 	30.1 	A2-2840, 	RHC-320 	Content and Terms of Provider Participation Agreements
1 	30.1.1 	RHC-321 	Provider Charges to Beneficiaries
1 	30.1.2 	RHC-322 	Provider Refunds to Beneficiaries
1 	30.1.3 	RHC-323 	Provider Treatment of Beneficiaries
1 	30.2 	A3-3488,
A3- 3703.1
B3-3060 	Assignment of Provider's Right to Payment
1 	30.2.1 	Exceptions to Assignment of Provider's Right to Payment -
Claims Submitted to FIs and Carriers
1 	30.2.2 	B3-3045.1 	Background and Purpose of Reassignment Rules - Claims
Submitted to Carriers

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
Submitted to Carriers
1 	30.2.2.1 	A3-3005 	Reassignments by Nonphysician Suppliers - Claims Submitted to
FIs
1 	30.2.3 	Effect of Payment to Ineligible Recipient
1 	30.2.4 	A3-3488.1 	B3-3060.10 	Payment to Agent - Claims Submitted to Carriers
1 	30.2.5 	A3-3488.2 	B3-3060.11 	Payment to Bank
1 	30.2.6 	B3-3060.1 	Payment to Employer of Physician - Carrier Claims Only -
Carrier Claims Only
1 	30.2.7 	B3-3060.2 	Payment to Facility in Which Services Are Performed
1 	30.2.8 	B3-3060.3 	Carrier Payment to Health Care Delivery System - Claims
Submitted to Carriers
1 	30.2.8.1 	B3-3060.3C 	Definition of Health Care Delivery System
1 	30.2.8.2 	B3-3060.3D 	University-Affiliated Medical Faculty Practice Plans - Claims
Submitted to Carriers
1 	30.2.8.3 	B3-3060.3E,
B3-7065
Managed Care Organization, including HCPPs, Cost-Contracting
HMOs, CMPs, and Medicare + Choice Organizations - Claims
Submitted to Carriers
1 	30.2.9 	B3-3060.4,
R1813B3
Payment to Physician for Purchased Diagnostic Tests - Claims
Submitted to Carriers
1 	30.2.9.1 	B3-3060.5 	Payment to Supplier of Diagnostic Tests for Purchased
Interpretations

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	30.2.10 	B3-3060.6 	Payment Under Reciprocal Billing Arrangements - Claims
Submitted to Carriers
1 	30.2.11 	B3-3060.7 	Payment Under Locum Tenens Arrangements - Claims Submitted
to Carriers
1 	30.2.12 	B3-3060.8 	Establishing That a Person or Entity Qualifies to Receive
Payment on Basis of Reassignment - for Carrier Processed
Claims
1 	30.2.13 	B3-3060.9 	Billing Procedures for Entities Qualified to Receive Payment on
Basis of Reassignment - for Carrier Processed Claims
1 	30.2.14 	A3-3488.3 	B3-3060.6E.
B3-3060.12
Correcting Unacceptable Payment Arrangements
1 	30.2.14.1 	Questionable Payment Arrangements
1 	30.2.15 	A3-3488.4 	B3-3060.13,
B3-3060.14
Sanctions for Prohibited Payment Arrangement
1 	30.2.16 	A3-3488.5 	B3-3060.15,
B3-7065 partial
Prohibition of Assignments by Beneficiaries
1 	30.3 	A3-3005 	B3-17000 	Physician/Practitioner/Supplier Participation Agreement and
Assignment - Carrier Claims
1 	30.3.1 	B3-3040.4 	Mandatory Assignment on Carrier Claims
1 	30.3.1.1 	B-3040.3 	Processing Claims for Services of Participating Physicians or
Suppliers by Carriers
1 	30.3.2 	B3-3045.1 	Nature and Effect of Assignment on Carrier Claims

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	30.3.3 	B3-3045.2 	Physician's Right to Collect from Enrollee on Assigned Claim
Submitted to Carriers
1 	30.3.4 	B3-3045.3 	Effect of Assignment Upon Rental or Purchase of Durable
Medical Equipment on Claims Submitted to Carriers
1 	30.3.5 	B3-3045.4 	Effect of Assignment Upon Purchase of Cataract Glasses from
Participating Physician or Supplier on Claims Submitted to
Carriers
1 	30.3.6 	B3-3045.5 	Mandatory Assignment Requirement for Physician Office
Laboratories on Claims Submitted to Carriers
1 	30.3.7 	B3-3045.6 	Physicians Billing for Purchased Diagnostic Tests (Other Than
Clinical Diagnostic Laboratory Tests) on Claims Submitted to
Carriers
1 	30.3.8 	B3-3045.7 	Mandatory Assignment and Other Requirements for Home
Dialysis Supplies and Equipment Paid Under Method II on
Claims Submitted to Carriers
1 	30.3.9 	B3-3040 	Filing Claims to a Carrier For Nonassigned Services
1 	30.3.10 	B3-3040.1 	Carrier Submitted Bills by Beneficiary
1 	30.3.11 	B3-3040.2 	Carrier Receipted Bill - Definition
1 	30.3.12 	B3-17001 	Carrier Annual Participation Program
1 	30.3.12.1 	B3-17001.1 	Carrier Participation and Billing Limitations
1 	30.3.12.2 	B3-17001.1 	Carrier Participation Agreement

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	30.3.12.3 	B3-17002 	Carrier Rules for Limiting Charge
1 	40 	A3-3008,
A2-2800
Termination of Provider Agreement
1 	40.1 	A3-3008.1,
A2-2800.1
RHC-330,
OPT-124
Voluntary Termination
1 	40.1.1 	A2-2800.2 	RHC-330 	Close of Business
1 	40.1.2 	HHA-145,
HO-145;
SNF-145;
RHC-331,
RHC-332
Change of Ownership
1 	40.1.3 	A3-3008.3 	Expiration and Renewal-Nonrenewal of SNF Term Agreements
1 	40.2 	A3-3008.2 	RHC-331 	Involuntary Terminations
1 	40.2.1 	A2-2800.3 	Processing Involuntary Terminations
1 	40.2.2 	A2-2801,
A2-2801.1
Intermediary Report on Provider Deficiencies
1 	40.2.2.1 	A2-2801.2 	Subsequent Communications With Provider
1 	40.3 	A2-2804 	Readmission to Medicare Program After Involuntary Termination
1 	40.3.1 	A2-2804.1 	Effective Date of Provider Agreement
1 	40.3.2 	A2-2805 	RHC-334 	Fiscal Considerations In Provider Readmission To Medicare
Program After Involuntary Termination

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	40.4 	A3-3008.4 	Payment for Services Furnished After Termination, Expiration, or
Cancellation of Provider Agreement
1 	40.4.1 	A3-3600.3 	Reviewing Inpatient Bills for Services After Suspension,
Termination, Expiration, or Cancellation of Provider Agreement,
or After a SNF is Denied Payment for New Admissions
1 	40.4.2 	A3-3699.3.C 	Status of Hospital or SNF After Termination, Expiration, or
Cancellation of Its Agreement
1 	40.5 	A3-3600.7 	Intermediary/Carrier/DMERC Responsibilities for Informing
Providers of Changes
1 	50 	A3-3301 	Filing a Request for Payment With the Carrier or Intermediary
1 	50.1 	A3-3302 	Request for Payment from the Carrier or Intermediary
1 	50.1.1 	A3-3302.1,
A3-3602.4
Billing Form as Request for Payment
1 	50.1.2 	A3-3302.2 	Beneficiary Request for Payment on Provider Record - UB-92
and Electronic Billing (Part A and Part B)
1 	50.1.3 	A3-3302.5 	B3-3008 	Signature on the Request for Payment by Someone Other Than
the Patient
1 	50.1.4 	A3-3302.6 	Request for Payment as a Claim for HI Entitlement
1 	50.1.5 	A3-3302.7 	Refusal by Patient to Request Payment Under the Program
1 	50.1.6 	B3-3057 	When Beneficiary Statement is Not Required for
Physician/Supplier Claim

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	50.1.7 	A3-3305.1,
A3-3312.2,
B3-3004,
B3-3000 partial
Definition of a Claim for Payment
1 	50.1.8 	A3-3305.2,
A3-3305.3
Establishing Date of Filing - Postmark Date Carriers
1 	50.2 	A3-3603 	Frequency of Billing for Providers
1 	50.2.1 	Inpatient Billing from Hospitals and SNFs
1 	50.2.2 	Frequency of Billing for Outpatient and Services to
Intermediaries
1 	50.2.3 	A3-3603.1 	Submitting Bills In Sequence Ffor a Continuous Inpatient Stay or
Outpatient Course of Treatment
1 	A3-3603.2,
Definition of
spell of
illness from
MIM-3035
Reprocess Inpatient or Hospice Claims in Sequence
1 	60 	No Pay Bills
1 	70 	A3-3600.2 	Time Limitations for Filing Provider Claims
1 	70.1 	A3-3600.2A 	Determining Start Date of Timely Filing Period--Service Date
1 	70.2 	A3-3600.2B 	Definition of Claim
1 	70.2.1 	A3-3600.2B1 	Appropriate Medicare Contractor
1 	70.2.2 	A3-3600.2B2 	Form Prescribed by CMS

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	70.2.3 	A3-3600.2B3 	In Accordance with CMS Instructions
1 	70.2.3.1 	A3-
3600.2B3a
Incomplete or Invalid Submissions
1 	70.2.3.2 	A3-
3600.2B3b
Handling Incomplete or Invalid Submissions
1 	A3-
3600.2B3c
1 	70.3 	A3-3600.2C 	Determining End Date of Timely Filing Period—Receipt Date
1
1 	70.4 	A3-3600.2D 	Determination of Timely Filing and Resulting Actions
1 	70.4.1 	Part A Institutional Provider Services and Part A and Part B
Home Health Services
1 	70.5 	A3-3600.2E 	Application to Special Claim Types
1 	70.6 	A3-3600.2F 	Filing Claim Where Usual Time Limit Has Expired
1 	70.7 	A3-3600.2G 	Exceptions Allowing Extension of Time Limit
1 	70.7.1 	A3-3600.2G1 	Administrative Error
1 	70.7.2 	A3-3600.2G2 	Statement of Intent
1 	70.7.3 	A3-3600.2G3 	Reopening of Determinations

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	80 	A3-3600,
A3-3600.1
B3-13306,
B2-5240.11
HO-401,
HO-401A,
HH-462
Carrier and Intermediary Claims Processing Timeliness
1 	80.1 	Control and Counting Claims
1 	80.2 	A3-3600.1 	B2-5240.11A 	HO-401D 	Definition of Clean Claim
1 	80.2.1 	A3-3600.1-
Item 7
Receipt Date
1 	80.2.1.1 	A3-
3600.1A.1
B2-5240.11D 	Payment Ceiling Standards
1 	80.2.1.2 	A3-3600.1 	HO-401B 	Payment Floor Standards
1 	80.2.2 	A3-3600.1-
Item 5
HO-401C 	Interest Payment on Clean Non-PIP Claims Not Paid Timely
1 	80.2.2.1 	B2-5240.11C 	Determining and Paying Interest
1 	80.2.2.2 	Preparation of IRS Form 1099-INT
1 	80.3 	A3-3600.1-
Item 4
B2-5240.11B 	HO-401E 	Other Claims (Other Than Clean)
1 	80.3.1 	A3-3605.1 	B3-3005.1 	Incomplete or Invalid Claims Processing Terminology
1 	80.3.2 	A3-3605.2 	B3-3005.2B 	Handling Incomplete or Invalid Claims
1 	80.3.2.1 	A3 3605.3 	B3-3005.3, 	Data Element Requirements Matrix

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	80.3.2.1.1 	B3-3005.4,
R1813B3
Carrier Data Element Requirements
1 	80.3.2.1.2 	B3-3005.4,
R1813B3
Conditional Data Element Requirements for Carriers and
DMERCs
1 	80.3.2.1.3 	Carrier Specific Requirements for Certain Specialties/Services
1 	80.3.2.2 	A3-3606 	Intermediary Consistency Edits
1 	80.4 	A3-3676 	Enforcement of Provider Billing Timelines and Accuracy
Standard to Continue PIP (Periodic Interim Payment)
1 	80.5 	Do Not Forward Initiative (DNF)
1 	80.5.1 	B3-4021, 	B-02-023 	Carrier DNF Requirements
1 	80.5.1.1 	B-02-11 	Reporting Requirements - Carriers
1 	80.5.2 	A-02-12 	Intermediary DNF Requirements
1 	80.5.2.1 	Reporting Requirements - Intermediaries
1 	90 	HO-408,
HH-412
Patient Is a Member of an M+CO for Only a Portion of the
Billing Period
1 	100 	HO-301,
HO-469,
42 CFR 411.32
Medicare as a Secondary Payer
1 	110 	HO-413,
HH-480,
SNF 545
Provider Retention of Health Insurance Records

Chap 	Sect 	Int.
Pub. 13
Carrier
Pub. 14
PMs 	Other 	Description
1 	110.1 	HO-413,
HH-480,
SNF 545.1
Categories of Health Insurance Records to Be Retained
1 	110.2 	SNF 545.3,
HO-413,
HH-480
Microfilming Records
1 	110.3 	Retention Period
1 	110.4 	HO-413.1,
HH-480.1,
SNF 545.4
Destruction of Records
1 	130 	A3-3670 	AB-00-38 	Detection of Duplicate Claims
1 	B3-3999 	Exhibit 1 - Data Element Requirements Matrix (Carrier)