Partial Payment by Primary Payer for Inpatient Services, Outpatient Services,

40.2.1 - Partial Payment by Primary Payer for Inpatient Services, Outpatient Services, Part B Inpatient Services, and HHA Bills (Rev. 11874, Issued: 02-23-23, Effective: 03-24-23; Implementation: 03-24-23) A modified bill will be submitted if payment by the primary payer for Medicare covered services is less than the provider's charges for those services and the current Medicare interim payment amount (without regard to the deductible or coinsurance) and the provider does not accept (and is not obligated to accept) the primary payer's payment as payment in full, or the primary payment is less than the Medicare rate (without regard to the deductible and coinsurance), The bill will be submitted in accordance with Chapter 25, "Completing and Processing the Form CMS 1450 Data Set," of the Medicare Claims Processing Manual, with the following modifications: • The provider completes the total and noncovered charges as if there had been no other payment; • For inpatient hospital or SNF services, the provider completes total covered and non- covered days in the usual manner. It counts days paid by the primary payer as covered days; • The primary payer is identified on the first payer line in FL 50. Medicare is identified as the secondary or tertiary payer by completing the second or third payer line; • The appropriate primary payer value code and amount paid is shown in value code and amount fields; • The amount the provider is obligated to accept as payment in full from the primary payer when the primary payer pays a lesser amount is shown as value code 44; • The address of the primary payer is shown in Remarks (FL 84); and • If the primary payer is a GHP for an ESRD beneficiary, the provider enters occurrence code 33 and the first day of the first month of the Medicare coordination period. In addition, the provider enters the appropriate occurrence/condition codes in section 50 below.