- Avoid Processing Delays by Following Proper Submission Guidelines
- Medicare Beneficiary Eligibility Checklist
- Acceptable Electronic Signatures Reminder
- Capable Recipients for the Advance Beneficiary Notice of Noncoverage
- Hospital-Issued Notices of Noncoverage
- Medicare Advance Written Notices of Noncoverage Booklet
- Primary Care Exception Guidelines
- Ordering DMEPOS Items
- Appropriate Use Criteria Program
- Assistant at Surgery Billing Documentation Reminder
- Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process
- Checking Eligibility and Knowing Your Point of Contact
- Cloned Documentation Could Result in Medicare Denials for Payment
- Documentation Reminder: Psychiatry and Psychology Services
- Documentation Required for Home Visits
- Electrical Stimulation Therapy: Important Coverage and Documentation Reminders
- Go Paperless Today - Protect Your Bottom Line
- Hospital Acquired Conditions and Present on Admission Resource for Physicians
- Inpatient Admission Prior to Medicare Entitlement Job Aid
- MDS Calendar
- Medicare Home Health Collaboration with Other Provider Types
- Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
- Manual Review of Claims for Replacement of Supplies and Accessories used with External Ventricular Assist Device
- Referring, Monitoring and Certifying Home Health Services
- Scribing Medical Record Documentation
- Skilled Nursing Facility Medicare Part A Benefit Quick Reference Fact Sheet
- Submit Medical Record Documentation Electronically
- Submitting Electronic Medical Records via CD-ROM
- Using the Medicare Part B PWK Fax-Mail-esMD Cover Sheet
Inpatient Admission Prior to Medicare Entitlement Job Aid
Pre-Entitlement Quick Steps
Pre-entitlement is when a beneficiary is admitted as an inpatient to an acute care hospital prior to the beneficiary's Medicare entitlement effective date and is discharged after the Medicare Part A entitlement date.
The number of utilization days is calculated from the Medicare entitlement date through discharge/transfer/death. Utilization is not counted for any nonentitlement days even if those days are treated as covered for outlier calculation. Therefore, the services rendered during the entire stay are billed on the UB-04 as covered charges. The admission date will reflect the date of admission to the hospital, while the from/through dates will only reflect the actual entitlement through discharge.
When the beneficiary becomes entitled after admission, the hospital may not bill the beneficiary or other persons for days of care preceding entitlement except for days in excess of any outlier threshold. The entire stay is paid under the appropriate MS-DRG; therefore, no ancillary charges should be billed on a TOB 13X.
Note: Claims with a discharge date equal to the effective date of Medicare coverage cannot be billed as pre-entitlement claims.
Claims must be submitted following the steps below for the inpatient claim (11X claim type) to be processed correctly by Medicare:
- The Admission date Field Locator (FL) 12 equals the actual admission date to the hospital
- The statement covers from/through period (FL) 6 shows
- From Date equal to the effective date of Medicare Part A coverage
- Through Date equal to the discharge date from the hospital
- The covered days reflect the covered days billed in the statement covered period in (FL) 6
- Value Code 80 reflects covered days (equal to from/through date span) - include only the time the patient was entitled to Medicare Part A coverage
- Accommodation days/units (Room and Board Revenue Codes) (UB 04- FL 42 and FL 46) are equal to the covered day amount reported in value code 80
- Charges for room and board include only the time the patient was entitlement to Medicare Part A
- Do not report noncovered room and board charges for the time the patient was not entitled to Medicare Part A
- Report
- All revenue codes from the admission date through the discharge/transfer/death date are billed as covered charges
- All applicable ICD-10-CM diagnosis codes from the admission date through the discharge/transfer/death date
- All applicable ICD-10-PCS procedure codes performed from the admission date to the discharge/transfer/death date
- Remarks (UB-04 FL 80) indicating the date Medicare Part A entitlement started
- Report all charges since admission; however, exclude room and board charges prior to Medicare Part A coverage
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Revised 7/23/2021