Medicare Claims

A. PPS 

Hospitals The A/B MACs (A) submit all records (past and current) for all PPS providers every three months. Duplicate the provider file used in the "PRICER" module of the claims processing system.

 B. Non-PPS Hospitals and Exempt Units 

The A/B MACs (A) create a provider specific history file using the listed data elements for each non-PPS hospital and exempt hospital unit. Submit the current and the preceding fiscal years every three months. Code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file. 

C. Hospice 

The A/B MACs (A) create a provider specific history file using the following data elements for each hospice. Submit the current and the preceding fiscal years every three months. Data elements 3, 4, 5, 6, 9, 10, 13, and 17 are required. All other data elements are optional for this provider type. 

Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required. Data element 35 is required for all hospices. Data elements 33 and 38 are optional and may be populated if needed. 

Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.

D. Skilled Nursing Facility (SNF) 

The A/B MACs (A) create a provider specific history file using the following data elements for each SNF beginning with their first cost reporting period that starts on or after July 1, 1998. 

The A/B MACs (A) submit the current and the preceding fiscal years every three months. For PPS-exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file. Data elements 3, 4, 5, 6, 9, 10, 13, 19, and 21 are required. All other data elements are optional for this provider type. 

Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required. Data element 35 is required for all SNFs. Data elements 33 and 38 are required if there is a special wage index. Effective October 1, 2005, through September 30, 2006, data elements 33 and 38 are required since there is a special wage index.

E. Home Health Agency (HHA) 

The A/B MACs (HHH) create a provider specific history file using the following data elements for each HHA. Regional home health A/B MACs (HHH) submit the current and the preceding fiscal years every three months. Data elements 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, and 19 are required. All other data elements are optional for this provider type. All fields must be zero filled if not completed. Update the effective date in data element 4 annually. Ensure that the current census division in data element 11 is not zero. Ensure that the waiver indicator in data element 8 is N. Ensure that the MSA code reported in data element 13 is a valid MSA code.

Return Codes for Pricer

The following return codes are calculated by PRICER and passed back to the calling program. Depending on the type of payment and case, return codes 30, 44, 33, 40 and 42 indicate that an outlier would be paid if the cost-to-charge ratio would rise by 20 percentage points. If a provider(s) (CCR rises by 10 percentage points and) meets the criteria of reconciliation, the CMS Central Office uses return codes 30, 44, 33, 40 and 42 to determine a smaller pool of claims for reprocessing claims due to outlier reconciliation.

Acute Care 

Return Code 00: Paid normal DRG payment. 

Return Code 02: Paid normal DRG payment plus a cost outlier. 

Return Code 14: Paid normal DRG payment with per diem days equal or greater than geometric mean length of stay. 

Return Code 16: Paid normal DRG payment plus a cost outlier with per diem days equal to or greater than geometric mean length of stay. 

Return Code 30: Paid normal DRG payment and indicates an outlier payment would be necessary if the CCR would increase by 20 percentage points. 

Return Code 44: Paid normal DRG payment with per diem days equal or greater than geometric mean length of stay and indicates an outlier payment would be necessary if the CCR would increase by 20 percentage points.

Transfer Cases 

Return Code 03: Paid a per diem payment to the transferring IPPS hospital (when the patient transfers to an IPPS hospital) up to and including the full DRG payment if the covered days are less than the geometric mean length of stay for the DRG. If covered days equal or exceed the geometric mean length of stay, the standard payment is calculated. 

Return Code 05: Paid a per diem payment to the transferring IPPS hospital (when the patient transfers to an IPPS hospital) up to and including the full DRG payment if the covered days are less than the geometric mean length of stay for the DRG. If covered days equal or exceed the geometric mean length of stay, the standard payment is calculated. Also indicates case qualified for a cost outlier payment.

 Return Code 06: Paid a per diem payment to the transferring IPPS hospital (when the patient transfers to an IPPS hospital) up to and including the full DRG payment if the covered days are less than the geometric mean length of stay for the DRG. If covered days equal or exceed the geometric mean length of stay, the standard payment is calculated. Also indicates provider refused cost outlier payment. 

Return Code 33: Paid a per diem payment to the transferring IPPS hospital (when the patient transfers to an IPPS hospital) up to and including the full DRG payment if the covered days are less than the geometric mean length of stay for the DRG. If covered days equal or exceed the geometric mean length of stay, the standard payment is calculated. Also indicates an outlier payment would be necessary if the CCR increased by 20 percentage points.

List of Data Elements for FISS Extract

Provider # 

Health Insurance Claim (HIC) Number 

Document Control Number (DCN) 

Type of Bill 

Original Paid Date 

Statement From Date 

Statement To Date 

Original Reimbursement Amount (claims page 10) 

Revised Reimbursement Amount (claim page 10) 

Difference between these amounts 

Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1) 

Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1) 

Difference between these amounts 

Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2) 

Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2) 

Difference between these amounts 

Original Medicare Lifetime Reserve Amount in the first calendar year period (Value Code 08) Revised Medicare Lifetime Reserve Amount in the first calendar year period (Value Code 08) Difference between these amounts 

Original Medicare Coinsurance Amount in the first calendar year period (Value Code 09) 

Revised Medicare Coinsurance Amount in the first calendar year period (Value Code 09) 

Difference between these amounts 

Original Medicare Lifetime Reserve Amount in the second calendar year period (Value code 10) Revised Medicare Lifetime Reserve Amount in the second calendar year period (Value code 10) Difference between these amounts 

Original Medicare Coinsurance Amount in the second calendar year period (Value code 11) 

Revised Medicare Coinsurance Amount in the second calendar year period (Value code 11) Difference between these amounts

Original Outlier Amount (Value Code 17) 

Revised Outlier Amount (Value Code 17)

Difference between these amounts Original DSH Amount (Value Code 18) 

Revised DSH Amount (Value Code 18) 

Difference between these amounts Original IME Amount (Value Code 19) 

Revised IME Amount (Value Code 19) 

Difference between these amounts Original New Tech Add-on (Value Code 77)

Revised New Tech Add-on (Value Code 77) 

Difference between these amounts 

Original Device Reductions (Value Code D4) 

Revised Device Reductions (Value Code D4) 

Difference between these amounts TOT CHRG – total billed charges (claim page 3) 

COV CHRG – total covered charges (claim page 3) 

Original Hospital Portion (claim page 14)

 Revised Hospital Portion (claim page 14) 

Difference between these amounts 

Original Federal Portion (claim page 14) 

Revised Federal Portion (claim page 14) 

Difference between these amounts

 Original C TOT PAY (claim page 14) Revised C TOT PAY (claim page 14) 

Difference between these amounts Original C FSP (claim page 14) 

Revised C FSP (claim page 14) Difference between these amounts 

Original C OUTLIER (claim page 14) 

Revised C OUTLIER (claim page 14)

 Difference between these amounts Original C DSH ADJ (claim page 14) 

Revised C DSH ADJ (claim page 14) 

Difference between these amounts Original C IME ADJ (claim page 14) 

Revised C IME ADJ (claim page 14) 

Difference between these amounts Original Pricer Amount Revised Pricer Amount 

Difference between these amounts Original PPS Payment (claim page 14) 

Revised PPS Payment (claim page 14) 

Difference between these amounts

Original PPS Return Code (claim page 14) 

Revised PPS Return Code (claim page 14)

 Original UNCOMP CARE AMT (claim page 40) 

Revised UNCOMP CARE AMT (claim page 40) 

Difference between these amounts Original VAL PURC ADJ AMT (claim page 40) 

Revised VAL PURC ADJ AMT (claim page 40) 

Difference between these amounts Original READMIS ADJ AMT (claim page 40) 

Revised READMIS ADJ AMT (claim page 40) 

Difference between these amounts Original HAC PAYMENT AMT (claim page 40) 

Revised HAC PAYMENT AMT (claim page 40) 

Difference between these amounts Original EHR PAY ADJ AMT (claim page 40) 

Revised EHR PAY ADJ AMT (claim page 40) 

Difference between these amounts Original PPS-ISLET-ADD-ON-AMT (Value Code Q7) 

Revised PPS-ISLET-ADD-ON-AMT (Value Code Q7) 

Difference between these amounts DRG 

MSP Indicator (Value Codes 12-16 & 41-43 – indicator indicating the claim is MSP; ‘Y’ = MSP, ‘blank’ = no MSP Reason Code 

HMO-IME Indicator 

Filler