Revocation Format

40.2.1 - Revocation Format (Rev. 257, Issued: 03-01-19, Effective: 04- 01-19 Implementation: 04- 01-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. The revocation of an election not to use reserve days should specify the name of the hospital, the admission date of the stay to which it applies and, if appropriate, the effective date of revocation. The following model language is suggested: Revocation of Election Not To Use Lifetime Reserve Days I wish to revoke the election previously made by me or on my behalf not to use lifetime reserve days to pay for the inpatient hospital services furnished me by (name of hospital) during my stay there beginning (admission date). (If appropriate add: I wish to revoke my election not to use lifetime reserve days for the period from _____to_____.) I understand that my lifetime reserve days will be used for these services (to the extent that I have such days available) but that I will still be responsible to pay the Medicare coinsurance amounts and any charges for services not covered under the Medicare program. (Signature) (Date) (Medicare beneficiary identifier)