Provider Problems Obtaining Entitlement Information

30.22 - Provider Problems Obtaining Entitlement Information (Rev. 3441, Issued: 01-15-16, Effective; 12-31-13; ASC X12: 01-01-12, MAC Implementation: 02-16-16; ASC X12: 02-16-16) If after application of the above procedures, the provider encounters significant problems in obtaining information regarding Medicare entitlement or benefits in order to accurately prepare bills, the provider should contact the A/B MAC (A), (B), or (HHH), or DME MAC for assistance. However, these requests should be on a non-routine basis. The MAC will assist providers in obtaining entitlement information. The MAC may temporarily refuse assistance if a pattern of abuse is discovered. Situations that may require MAC assistance are: • When the patient dies following admission. It may be necessary to file timely with an estate; • When the patient is not in a physical or mental condition to discuss his/her entitlement, and no other person with knowledge of the patient’s affairs is available; • When the provider has reason to believe the beneficiary may need lifetime reserve days, and his/her signature must be obtained if the available lifetime reserve days are not to be used for this admission and other financial arrangements must be made; • When it is suspected that the beneficiary may have exhausted his/her Medicare benefits, and timely confirmation is needed in order to file for possible supplemental benefits; and • When the patient has experienced repeated admissions during the same spell of illness, and determining available benefits for the beneficiary is difficult.