Outpatient Bills, Part B Inpatient Services, and Home Health Agency

40.1.2 - Outpatient Bills, Part B Inpatient Services, and Home Health Agency (HHA) Bills (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) No bill is submitted if: • Payment by the primary payer for Medicare covered services equals or exceeds: o The provider's charges for those services, or o The current Medicare interim payment amount (without regard to the deductible or coinsurance), or the provider accepts (or is obligated to accept) the primary payer's payment as payment in full (and it receives at least this amount) and the provider knows the individual has already met the deductible. • A GHP payment for an ESRD beneficiary equals or exceeds the Medicare rate (without regard to the deductible or coinsurance) and the hospital-based renal dialysis facility knows the individual has met the deductible; and • Where an HHA is billing for DME or orthotic/prosthetic devices and the patient is not under a plan of treatment and the provider knows the individual has met the deductible. A bill is submitted to: • Inform Medicare of charges where the deductible may not yet be met. Although Medicare can make no payment, it can apply the expenses to the beneficiary's deductible. A bill is required for crediting the deductible. The provider completes the bill in the usual manner and determines the charges including those covered by the primary payer's payment. The amount paid by the primary payer for Medicare covered services is reported in the appropriate value code and amount. See section 50 below for additional MSP data elements that may apply to the bill based on the applicable MSP provision. The provider enters condition code 77 when it receives the amount it is obligated to accept from the primary payer as payment in full.