Medicare Claims Processing Manual
Chapter 1 - General Billing Requirements
Table of Contents
(Rev. 12511, Issued: 02-15-24)
Transmittals for Chapter 1
01 - Foreword
01.1 - Remittance Advice Coding Used in this Manual 02 -
Formats for Submitting Claims to Medicare
02.1 - Electronic Submission Requirements
02.1.1 - HIPAA Standards for Claims
02.1.2 - Where to Purchase HIPAA Standard Implementation Guides
02.2 - Paper Claims
02.2.1 - Paper Formats for Institutional Claims
02.2.2 - Paper Formats for Professional and Supplier Claims
02.3 - Remittance Advices 10 -
Jurisdiction for Claims
10.1 - A/B MACs (Part B) and DME MACs Jurisdiction of Requests for Payment
10.1.1 - Payment Jurisdictions Among A/B MACs (B) for Services Paid
Under the Physician Fee Schedule and Anesthesia Services
10.1.1.1 - Claims Processing Instructions for Payment Jurisdiction
10.1.1.2 - Payment Jurisdiction for Services Subject to the Anti-Markup
Payment Limitation
10.1.1.3 - Payment Jurisdiction for Reassigned Services
10.1.3 - Exceptions to Jurisdictional Payment
10.1.5 - Domestic Claims Processing Jurisdictions
10.1.5.1 - Suppliers of Durable Medical Equipment, Prosthetics, Orthotics,
Supplies, Parental and Enteral Nutrition (PEN)
10.1.5.2 - Supplier of Portable X-Ray, EKG, or Similar Portable Services
10.1.5.3 - Ambulance Services Submitted to Carriers
10.1.5.4 - Independent Laboratories
10.1.5.4.1 - Cases Involving Referral Laboratory Services
10.1.6 - Railroad Retirement Beneficiary Carrier
10.1.7 - Welfare Carriers
, 10.1.9 - Disposition of Misdirected Claims to the B/MAC/Carrier/DME MAC
10.1.9.1 - An A/B MAC (B) Receives a Claim for Services that are in
Another A/B MAC (B)’s Payment Jurisdiction
10.1.9.2 – An A/B MAC (B) Receives a Claim for Services that are in a
DME MAC’s Payment Jurisdiction
10.1.9.3 – A DME MAC Receives a Claim for Services that are in A
Local B/MAC/Carrier’s Payment Jurisdiction
10.1.9.4 - An A/B MAC (B) Receives a Claim for an RRB Beneficiary
10.1.9.5 - An A/B MAC (B) or DME MAC Receives a Claim for a
UMWA Beneficiary
10.1.9.6 - Medicare Carrier or RRB-Named Carrier to Welfare Carrier
10.1.9.7 - Protests Concerning Transfer of Requests for Payment to Carrier
10.1.9.8 - Transfer of Claims Material Between Carrier and Intermediary
(FI)
10.1.9.9 - A DME MAC receives a Paper Claim with Items or Services
that are in Another DME MAC's Payment Jurisdiction
10.2 - FI Jurisdiction of Requests for Payment
10.2.1 - FI Payment for Emergency and Foreign Hospital Services
10.3 - Payments Under Part B for Services Furnished by Suppliers of Services to
Patients of a Provider
10.4 - Claims Submitted for Items or Services Furnished to Medicare
Beneficiaries in State or Local Custody Under a Penal Authority
10.5 – Claims Processing Requirements for Deported Beneficiaries
10.5.1 – Implementation of Payment Policy for Deported Beneficiaries 20
- Provider Assignment to FIs and MACs
20.1 - FI Service to HHAs and Hospices
20.2 - Provider Change of Ownership (CHOW)
20.3 - CMS No Longer Accepts Provider Requests to Change Their FI 30
- Provider Participation
30.1 - Content and Terms of Provider Participation Agreements
30.1.1 - Provider Charges to Beneficiaries
30.1.1.1 - Charges to Hold a Bed During SNF Absence
30.1.2 - Provider Refunds to Beneficiaries
30.1.3 - Provider Treatment of Beneficiaries
30.2 - Assignment of Provider’s Right to Payment
30.2.1 - Exceptions to Assignment of Provider’s Right to Payment - Claims
Submitted to A/B MACs
30.2.2 - Background and Purpose of Reassignment Rules - Claims
Submitted to B/MACs
30.2.2.1 - Reassignments by Nonphysician Suppliers - Claims
, Submitted to FIs
30.2.3 - Effect of Payment to Ineligible Recipient
30.2.4 - Payment to Agent - Claims Submitted to Carriers
30.2.5 - Payment to Bank
30.2.6 - Payment to Employer of Physician - Carrier Claims Only
30.2.7 - Payment for Services Provided Under a Contractual Arrangement
- Carrier Claims Only
30.2.8.2 - University-Affiliated Medical Faculty Practice Plans -
Claims Submitted to Carriers
30.2.8.3 - Indirect Payment Procedure (IPP) - Payment to Entities that
Provide Coverage Complementary to Medicare Part B
30.2.9 - Payment to Physician or Other Supplier for Purchased Diagnostic
Tests Subject to the Anti-Markup Payment Limitation-Claims Submitted
to A/B MACs (Part B)
30.2.10 - Payment Under Reciprocal Billing Arrangements - Claims Submitted
to A/B MACs Part B
30.2.11 - Payment Under Fee-For-Time Compensation Arrangements
(formerly referred to as Locum Tenens Arrangements) - Claims Submitted
to A/B MACs Part B
30.2.12 - Establishing That a Person or Entity Qualifies to Receive
Payment on Basis of Reassignment - for Carrier Processed Claims
30.2.13 - Billing Procedures for Entities Qualified to Receive Payment on
Basis of Reassignment - for A/B MAC Part B Processed Claims
30.2.14 - Correcting Unacceptable Payment Arrangements
30.2.14.1 - Questionable Payment Arrangements
30.2.15 - Sanctions for Prohibited Payment Arrangement
30.2.16 - Prohibition of Assignments by Beneficiaries
30.3 - Physician/Practitioner/Supplier Participation Agreement and Assignment -
Carrier Claims
30.3.1 - Mandatory Assignment on Carrier Claims
30.3.1.1 - Processing Claims for Services of Participating Physicians
or Suppliers
30.3.2 - Nature and Effect of Assignment on Carrier Claims
30.3.3 - Physician’s Right to Collect From Enrollee on Assigned Claim
Submitted to Carriers
30.3.4 - Effect of Assignment Upon Rental or Purchase of Durable
Medical Equipment on Claims Submitted to Carriers
30.3.5 - Effect of Assignment Upon Purchase of Cataract Glasses From
Participating Physician or Supplier on Claims Submitted to Carriers
30.3.6 - Mandatory Assignment Requirement for Physician Office
Laboratories on Claims Submitted to Carriers
, 30.3.7 - Billing for Diagnostic Tests (Other Than Clinical Diagnostic
Laboratory Tests) Subject to the Anti-Markup Payment Limitation - Claims
Submitted to A/B MACs (B)
30.3.8 - Mandatory Assignment and Other Requirements for Home
Dialysis Supplies and Equipment Paid Under Method II on Claims Submitted
to Carriers
30.3.9 - Filing Claims to a Carrier for Nonassigned Services
30.3.10 - Carrier Submitted Bills by Beneficiary
30.3.11 - Carrier Receipted Bill - Definition
30.3.12 - Carrier Annual Participation Program
30.3.12.1 - Annual Open Participation Enrollment Process
30.3.12.1.2 - Annual Medicare Physician Fee Schedule File
Information
30.3.12.2 - Carrier/MACs Participation Agreement
30.3.12.3 - Carrier Rules for Limiting Charge
30.3.13 - Charges for Missed Appointments 40
- Termination of Provider Agreement
40.1 - Voluntary Termination
40.1.1 - Close of Business
40.1.2 - Change of Ownership
40.1.3 - Expiration and Renewal-Nonrenewal of SNF Term Agreements
40.2 - Involuntary Terminations
40.2.1 - Processing Involuntary Terminations
40.2.2 - FI Report on Provider Deficiencies
40.2.2.1 - Subsequent Communications With Provider
40.3 - Readmission to Medicare Program After Involuntary Termination
40.3.1 - Effective Date of Provider Agreement
40.3.2 - Fiscal Considerations in Provider Readmission to Medicare
Program After Involuntary Termination
40.4 - Payment for Services Furnished After Termination, Expiration, or
Cancellation of Provider Agreement
40.4.1 - Reviewing Inpatient Bills for Services After Suspension,
Termination, Expiration, or Cancellation of Provider Agreement, or After
a SNF is Denied Payment for New Admissions
40.4.2 - Status of Hospital or SNF After Termination, Expiration, or
Cancellation of Its Agreement
40.5 - FI/Carrier/DMERC Responsibilities for Informing Providers of Changes 50
- Filing a Request for Payment With the Carrier or FI
50.1 - Request for Payment From the Carrier or FI
50.1.1 - Billing Form as Request for Payment
Chapter 1 - General Billing Requirements
Table of Contents
(Rev. 12511, Issued: 02-15-24)
Transmittals for Chapter 1
01 - Foreword
01.1 - Remittance Advice Coding Used in this Manual 02 -
Formats for Submitting Claims to Medicare
02.1 - Electronic Submission Requirements
02.1.1 - HIPAA Standards for Claims
02.1.2 - Where to Purchase HIPAA Standard Implementation Guides
02.2 - Paper Claims
02.2.1 - Paper Formats for Institutional Claims
02.2.2 - Paper Formats for Professional and Supplier Claims
02.3 - Remittance Advices 10 -
Jurisdiction for Claims
10.1 - A/B MACs (Part B) and DME MACs Jurisdiction of Requests for Payment
10.1.1 - Payment Jurisdictions Among A/B MACs (B) for Services Paid
Under the Physician Fee Schedule and Anesthesia Services
10.1.1.1 - Claims Processing Instructions for Payment Jurisdiction
10.1.1.2 - Payment Jurisdiction for Services Subject to the Anti-Markup
Payment Limitation
10.1.1.3 - Payment Jurisdiction for Reassigned Services
10.1.3 - Exceptions to Jurisdictional Payment
10.1.5 - Domestic Claims Processing Jurisdictions
10.1.5.1 - Suppliers of Durable Medical Equipment, Prosthetics, Orthotics,
Supplies, Parental and Enteral Nutrition (PEN)
10.1.5.2 - Supplier of Portable X-Ray, EKG, or Similar Portable Services
10.1.5.3 - Ambulance Services Submitted to Carriers
10.1.5.4 - Independent Laboratories
10.1.5.4.1 - Cases Involving Referral Laboratory Services
10.1.6 - Railroad Retirement Beneficiary Carrier
10.1.7 - Welfare Carriers
, 10.1.9 - Disposition of Misdirected Claims to the B/MAC/Carrier/DME MAC
10.1.9.1 - An A/B MAC (B) Receives a Claim for Services that are in
Another A/B MAC (B)’s Payment Jurisdiction
10.1.9.2 – An A/B MAC (B) Receives a Claim for Services that are in a
DME MAC’s Payment Jurisdiction
10.1.9.3 – A DME MAC Receives a Claim for Services that are in A
Local B/MAC/Carrier’s Payment Jurisdiction
10.1.9.4 - An A/B MAC (B) Receives a Claim for an RRB Beneficiary
10.1.9.5 - An A/B MAC (B) or DME MAC Receives a Claim for a
UMWA Beneficiary
10.1.9.6 - Medicare Carrier or RRB-Named Carrier to Welfare Carrier
10.1.9.7 - Protests Concerning Transfer of Requests for Payment to Carrier
10.1.9.8 - Transfer of Claims Material Between Carrier and Intermediary
(FI)
10.1.9.9 - A DME MAC receives a Paper Claim with Items or Services
that are in Another DME MAC's Payment Jurisdiction
10.2 - FI Jurisdiction of Requests for Payment
10.2.1 - FI Payment for Emergency and Foreign Hospital Services
10.3 - Payments Under Part B for Services Furnished by Suppliers of Services to
Patients of a Provider
10.4 - Claims Submitted for Items or Services Furnished to Medicare
Beneficiaries in State or Local Custody Under a Penal Authority
10.5 – Claims Processing Requirements for Deported Beneficiaries
10.5.1 – Implementation of Payment Policy for Deported Beneficiaries 20
- Provider Assignment to FIs and MACs
20.1 - FI Service to HHAs and Hospices
20.2 - Provider Change of Ownership (CHOW)
20.3 - CMS No Longer Accepts Provider Requests to Change Their FI 30
- Provider Participation
30.1 - Content and Terms of Provider Participation Agreements
30.1.1 - Provider Charges to Beneficiaries
30.1.1.1 - Charges to Hold a Bed During SNF Absence
30.1.2 - Provider Refunds to Beneficiaries
30.1.3 - Provider Treatment of Beneficiaries
30.2 - Assignment of Provider’s Right to Payment
30.2.1 - Exceptions to Assignment of Provider’s Right to Payment - Claims
Submitted to A/B MACs
30.2.2 - Background and Purpose of Reassignment Rules - Claims
Submitted to B/MACs
30.2.2.1 - Reassignments by Nonphysician Suppliers - Claims
, Submitted to FIs
30.2.3 - Effect of Payment to Ineligible Recipient
30.2.4 - Payment to Agent - Claims Submitted to Carriers
30.2.5 - Payment to Bank
30.2.6 - Payment to Employer of Physician - Carrier Claims Only
30.2.7 - Payment for Services Provided Under a Contractual Arrangement
- Carrier Claims Only
30.2.8.2 - University-Affiliated Medical Faculty Practice Plans -
Claims Submitted to Carriers
30.2.8.3 - Indirect Payment Procedure (IPP) - Payment to Entities that
Provide Coverage Complementary to Medicare Part B
30.2.9 - Payment to Physician or Other Supplier for Purchased Diagnostic
Tests Subject to the Anti-Markup Payment Limitation-Claims Submitted
to A/B MACs (Part B)
30.2.10 - Payment Under Reciprocal Billing Arrangements - Claims Submitted
to A/B MACs Part B
30.2.11 - Payment Under Fee-For-Time Compensation Arrangements
(formerly referred to as Locum Tenens Arrangements) - Claims Submitted
to A/B MACs Part B
30.2.12 - Establishing That a Person or Entity Qualifies to Receive
Payment on Basis of Reassignment - for Carrier Processed Claims
30.2.13 - Billing Procedures for Entities Qualified to Receive Payment on
Basis of Reassignment - for A/B MAC Part B Processed Claims
30.2.14 - Correcting Unacceptable Payment Arrangements
30.2.14.1 - Questionable Payment Arrangements
30.2.15 - Sanctions for Prohibited Payment Arrangement
30.2.16 - Prohibition of Assignments by Beneficiaries
30.3 - Physician/Practitioner/Supplier Participation Agreement and Assignment -
Carrier Claims
30.3.1 - Mandatory Assignment on Carrier Claims
30.3.1.1 - Processing Claims for Services of Participating Physicians
or Suppliers
30.3.2 - Nature and Effect of Assignment on Carrier Claims
30.3.3 - Physician’s Right to Collect From Enrollee on Assigned Claim
Submitted to Carriers
30.3.4 - Effect of Assignment Upon Rental or Purchase of Durable
Medical Equipment on Claims Submitted to Carriers
30.3.5 - Effect of Assignment Upon Purchase of Cataract Glasses From
Participating Physician or Supplier on Claims Submitted to Carriers
30.3.6 - Mandatory Assignment Requirement for Physician Office
Laboratories on Claims Submitted to Carriers
, 30.3.7 - Billing for Diagnostic Tests (Other Than Clinical Diagnostic
Laboratory Tests) Subject to the Anti-Markup Payment Limitation - Claims
Submitted to A/B MACs (B)
30.3.8 - Mandatory Assignment and Other Requirements for Home
Dialysis Supplies and Equipment Paid Under Method II on Claims Submitted
to Carriers
30.3.9 - Filing Claims to a Carrier for Nonassigned Services
30.3.10 - Carrier Submitted Bills by Beneficiary
30.3.11 - Carrier Receipted Bill - Definition
30.3.12 - Carrier Annual Participation Program
30.3.12.1 - Annual Open Participation Enrollment Process
30.3.12.1.2 - Annual Medicare Physician Fee Schedule File
Information
30.3.12.2 - Carrier/MACs Participation Agreement
30.3.12.3 - Carrier Rules for Limiting Charge
30.3.13 - Charges for Missed Appointments 40
- Termination of Provider Agreement
40.1 - Voluntary Termination
40.1.1 - Close of Business
40.1.2 - Change of Ownership
40.1.3 - Expiration and Renewal-Nonrenewal of SNF Term Agreements
40.2 - Involuntary Terminations
40.2.1 - Processing Involuntary Terminations
40.2.2 - FI Report on Provider Deficiencies
40.2.2.1 - Subsequent Communications With Provider
40.3 - Readmission to Medicare Program After Involuntary Termination
40.3.1 - Effective Date of Provider Agreement
40.3.2 - Fiscal Considerations in Provider Readmission to Medicare
Program After Involuntary Termination
40.4 - Payment for Services Furnished After Termination, Expiration, or
Cancellation of Provider Agreement
40.4.1 - Reviewing Inpatient Bills for Services After Suspension,
Termination, Expiration, or Cancellation of Provider Agreement, or After
a SNF is Denied Payment for New Admissions
40.4.2 - Status of Hospital or SNF After Termination, Expiration, or
Cancellation of Its Agreement
40.5 - FI/Carrier/DMERC Responsibilities for Informing Providers of Changes 50
- Filing a Request for Payment With the Carrier or FI
50.1 - Request for Payment From the Carrier or FI
50.1.1 - Billing Form as Request for Payment
