Determining Covered and Noncovered Charges - Pricer and PS&R

40.2.3 - Determining Covered and Noncovered Charges - Pricer and PS&R (Rev. 1, 10-01-03) Accommodation charges for days covered by Medicare are covered charges. Ancillary charges incurred on these days are also covered charges as long as these services are covered under Medicare. The A/B MAC (A) enters them into its PS&R unless it or the QIO denies them as exclusions from coverage or as medically unnecessary. For PPS hospitals, the A/B MAC (A) counts these charges for Pricer unless the charges are included as pass-through costs. The A/B MAC (A) does not count for Pricer or the PS&R: • Charges the provider has shown as noncovered. (If the provider has complied with the notice requirements in Chapter 30, it may bill the beneficiary.); • Services on noncovered days; • Charges for personal comfort and/or convenience items; • Accommodations and routine charges for the day of discharge, death, or beginning of a leave of absence, unless it is also the day of admission; and • Charges for ancillary services on the day of discharge, death, or beginning of a leave of absence if the preceding day is noncovered under §40.2.B. MSP Issues The A/B MAC (A) resolves any MSP issues not handled by §40.1.G using the instructions in the Medicare Secondary Payer Manual specific for reasonable cost providers and the instructions in specifically for PPS providers. Determining Covered and Noncovered Charges - Part B The A/B MAC (A) counts as covered under Part B, for cost report and deductible purposes, the charges for which Part B payment may be made, except as follows: • It counts as covered for deductible, but not cost report purposes, those charges for which the provider is liable for technical reasons; and • It does not count charges for which the provider is liable because services are not medically necessary for either deductible or cost report purposes.