100-02 Medicare Benefit Policy Manual: Chapter 16 Crosswalk

Medicare Benefit Policy Manual
Chapter 16 - General Exclusions from Coverage
Crosswalks
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16 	10 	A3-3150 	B3-2300 	HO-260 	HHA-232 	General Exclusions From Coverage
16 	20 	A3-3151 	B3-2303 	HO-260.1 	AB-00-52 	Services Not Reasonable and Necessary
16 	30 	Footcare
16 	40 	A3-3152 	B3-2306 	HO-260.2 	No Legal Obligation to Pay for or
Provide Services
16 	40.1 	A3-3152A 	HO-260.2A 	Indigence
16 	40.2 	A3-3152B 	HO-260.2B 	Provider, Physician, or Supplier Bills
Only Insured Patients
16 	40.3 	A3-3152C 	HO-260.2C 	Medicare Patient Has Other Health
Coverage
16 	40.4 	A3-3152D 	HO-260.2D 	Items Covered Under Warranty
16 	40.5 	A3-3152E 	HO-260.2E 	Members of Religious Orders
16 	40.6 	B3-2306 	Ambulance Services
16 	50 	A3-3153 	B3-2309 	HO-260.3 	Items and Services Furnished, Paid for or
Authorized by Governmental Entities -
Federal, State or Local Governments

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16 	50.1 	A3-3153.1 	B3-2309.2 	HO-260.3B 	Items and Services Which a Non-Federal
Provider Furnishes Pursuant to an
Authorization Issued by a Federal
Agency
16 	50.1.1 	A3-3153.1A,
A3-3153.1E
B3-2309.2 	HO-260.3B 	VA Authorized Services
16 	50.1.2 	A3-3153.1C 	HO-260.3B 	Medicare Secondary Payment Where VA
Authorizes Fewer Days Than Total
Number of Covered Days In the Stay
16 	50.1.3 	A3-3153.1D 	HO-260.3B 	Effect of VA Payments on Medicare
Deductible and Utilization
16 	50.1.4 	B3-2309.2 	VA "Fee Basis Card"
16 	50.1.5 	A3-3153.1B 	B3-2309.3 	HO-260.3A.2 	Services Authorized by Indian Health
Service
16 	50.2 	A3-3153.2 	B3-2309.1 	HO-260.3A 	Items and Services Furnished by Federal
Provider of Services or Federal Agency
16 	50.3 	A3-3153.3 	B3-2309.4 	HO-260.3C 	Items or Services Paid For by
Governmental Entity
16 	50.3.1 	A3-3153.3A 	HO-260.3C 	Application of Exclusion to State and
Local Government Providers
16 	50.3.2 	A3-3153.3B 	B3-2309.4 	HO-260.3D 	Application of Exclusion to
Nongovernmental Providers

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16 	50.3.3 	A3-3153.3C 	HO-260.3E 	PM-AB-02-097 	Examples of Application of Government
Entity Exclusion
16 	50.4 	A3-3153.3D 	HO-260.3F 	TRICARE and CHAMPVA (Civilian
Health and Medical Program of Veterans
Administration
16 	50.5 	A3-3153.3E 	HO-260.3G 	Active Duty Members of Uniformed
Services
16 	60 	A3-3154 	HO-260.4 	Services Not Provided Within United
States
16 	70 	A3-3155 	B3-2315 	HO-260.5 	Services Resulting from War
16 	80 	A3-3156 	B3-2318 	HO-290.6 	Personal Comfort Items
16 	90 	A3-3157 	B3-2320 	HO-260.7 	R-1797A3 -
5/00
Routine Services and Appliances
16 	100 	Hearing Aids and Cochlear Implants
16 	110 	A3-3159 	B3-2326 	HO-260.10,
HO-261
Custodial Care
16 	110.1 	A3-3159.1 	Custodial Care Under A Hospice
Program
16 	120 	A3-3160 	B3-2329 	HO-260.11 	Cosmetic Surgery
16 	130 	A3-3161 	B3-2332 	HO-260.12 	Charges Imposed by Immediate
Relatives of the Patient or Members of
the Patient's Household

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16 	140 	A3-3162 	B3-2336 	HO-260.13 	Dental Services Exclusion
16 	150 	A3-3163 	B3-2370 	HO-260.14 	Items and Services under a Workers'
Compensation Law
16 	170 	A3-3164 	B3-2390 	HO-260.15 	PM A 00-88 	Inpatient Hospital or SNF Services Not
Delivered Directly or under Arrangement
by the Provider
16 	180 	A3-3101.14 	B3-2300.1 	HO-210.12 	Services Related to and Required as a
Result of Services Which Are Not
Covered Under Medicare